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TEXT-BOOK 



OF 



OTOLOGY 



FOR 



Physicians and Students 



In 32 Lectures 



BY 

FR. BEZOLD, M. D., Professor of Otology at the 
University of Munich 

AND 

FR. SIEBENMANN, M. D., Professor of Otology 
at the University of Basle 

TRANSLATED BY 

J. HOLINGER, M. D., 

of Chicago 



CHICAGO 

E. H. COLEGROVE CO. 

1908 



«<> 



LIBRARY Of 00N6KESS 



TwoO«plM R«ce!veG 

JAN 27 1908 

|OLA§* A XXt. «io, 

copy a. 



Copyright, 1907, 

BY 

J. HOLINGER.M.D. 



HAMMOND PRESS 
B. CONKEY COMPANY 
CHICAGO 



Preface of the Author (Abridged) 



Having taught otology for twenty-five years, I decided to condense 
in a text-book all that has developed, in the course of years and is worth 
being retained. This decision was inVesponSe to the wish of my disciples, 
many of whom are now professors of otology. The book is written for 
physicians and students. Its teachings differ in many respects from the 
ideas which prevail at present. Distinct advances will be found even 
outside of the direct clinical domain, in physiology and topography. 

Physiology gained fromi a- careful .study^of the changes of the sound- 
conducting and sound-perceiving apparatus and from the analysis of the 
influence of those changes upon the function of the organ of hearing. 
The clinical importance justifies the amount of space devoted to it. 

The topography of the ear and its surroundings is accurately de- 
scribed because it indicates the avenues frequented by the numerous 
diseases of the organ of hearing. 

Only those operations have been accurately described which the 
general practitioner may be called upon to perform. A description of 
the technic of the major operations, such as the opening of all the spaces 
of the middle ear, the operations on the sinus and bulbus, of otitic ab- 
scesses of the brain, etc., is worthless to the student if it is not supple- 
mented by years of training in some special clinic. 

The complications of diseases of the ear which require those opera- 
tions have been, however, carefully discussed, as it is the general prac- 
titioner who has to recognize the danger signals. 

The therapy which I advocate is stripped of all unnecessary ballast. 
To many it may appear simple, to the general practitioner this simplicity 
may mark its greatest advantage. 

On account of illness the lectures XXVIII to XXXI were written 
by my former disciple, Prof. Siebenmann, who did a great deal of original 
research work on their subject, the diseases of the inner ear. 

The author limited himself to present what he recognized as of the 
greatest importance after years of careful discrimination and refrained 
from reproducing a large number of contradicting theories and methods. 

In order to obtain clearer views on many questions of my specialty, 
I have worked on anatomical, clinical, statistical and physiological prob- 

vii 



viii Preface of the Author (Abridged) 

lems uninterruptedly since my student days and have therefore to refer 
repeatedly to these investigations. Wherever matters are given that 
may be new to the men of our specialty I have entered into details and 
have referred to the literature. 

Other branches of science have profited by view points gained 
through the researches in the distant regions of our specialty. Of those 
sciences I might mention general medicine, physiology, our knowledge 
of the means of self-protection of the organism and the education of deaf- 
mutes. 



Preface of the Translator 



The need of a translation of Bezold's "Text-Book of Otology" be- 
came apparent among otologists, whenever, the discussion led to the 
subject of diagnosis of invisible diseases of the ears. This diagnosis 
was based on the characteristic changes of function. The great im- 
portance of this means of diagnosis becomes evident in our office and 
clinic every day, and ere long the otologist who is not thoroughly familiar 
with it will be in the same position as the surgeon who does not examine 
the function of a joint, of a stomach, of a bladder, etc., which he is called 
upon to treat. The negative proof for the accuracy of this diagnosis 
may be seen in the fact that no case as yet has been published where the 
pathologic diagnosis contradicted the functional diagnosis in the living. 
A positive proof was published last spring by Prof. Siebenmann, who 
demonstrated a labyrinth showing characteristic pathologic changes which 
had been predicted years previous by Prof. Bezold when only the changes 
of function in similar cases, but not their pathology was known. 

The general practitioner with scholarly proclivities will be interested 
also in the statistics of the various diseases of the ears, and in the chap- 
ters on pathology of the labyrinth, on deaf-mutism and on education of 
deaf-mutes. 

The book has been printed by W. B. Conkey & Co., who have in our 
opinion produced a first-class book in all respects. The entire expense 
of the publication has been undertaken by the translator. 

If I have succeeded in presenting the subject matter of "Bezold's 
Lehrbuch der Ohrenheilkunde" in a clear and concise manner and accept- 
able form I will have accomplished my object. 

In connection with this work I have received the aid from Dr. T. M. 
Hardie of Chicago, Dr. O. B. Monosmith of Lorain, Ohio, and Dr. D. T. 
Vail of Cincinnati, Ohio, and wish to thank these gentlemen most cor- 
dially for their kind services. 

Chicago, November, 1907. J. Holinger, m. d. 



IX 



CONTENTS 

GENERAL PART 

LECTURE I. 

PAGE 

Introduction 1 

LECTURE II. 
Division of the Organ of Hearing and Topography of the Temporal Bone 6 

LECTURE III. 
Methods of Examining the Ear 18 

LECTURE IV. 
Examination Through the Tube 25 

LECTURE V. 

Examination of the Middle Ear by Operation 32 

Examination Through the External Meatus 34 

LECTURE VI. 

The Picture of the Tympanic Membrane on Examination with the Ear Specu- 
lum 40 

LECTURE VII. 
Physiological Preface 47 

LECTURE VIII. 

Examination of Hearing by Means of Tones 56 

A. In Air Conduction , 56 

LECTURE IX. 

B. Examination of Bone Conduction 65 

Examination of Hearing by Speech 70 

Course of the Examination 76 

xi 



xii CONTENTS 



SPECIAL PART 

LECTURE X. 

PAGE 

Diseases of the External Ear 80 

Diseases of the Auricle and Its Surroundings 80 

General Considerations 80 

Deformities 81 

Eczema of the Auricle and Meatus 81 

LECTURE XL 

Othematoma . . . 86 

Perichondritis 87 

Erysipelas 88 

Other Affections of the Auricle and Its Surroundings 89 

Noma of the Cartilaginous Meatus, the Auricle and Its Surroundings .... 90 

Malignant Neoplasms of the Auricle and of the Meatus 95 

LECTURE XII. 

Diseases of the External Meatus 99 

General Part 99 

Congenital Atresia of the Meatus, Together with Rudimentary Auricle ... 99 

Exostoses and Hyperostoses of the Auditory Meatus. . . 102 

Acquired Atresia of the Auditory Canal 103 

Foreign Bodies in the Meatus 104 

Fractures of the Auditory Meatus 108 

Obturation of the Meatus by Gathering of Ear-wax and Masses of epider- 
mis 109 

LECTURE XIII. 

Circumscribed Inflammations of the External Meatus, Otitis Externa Cir- 
cumscripta (Furuncles, Abscesses) Ill 

The Different Forms of Otitis Externa Diffusa 113 

Otomycosis 115 

Otitis Externa Crouposa 119 

Otolithiasis 121 

LECTURE XIV. 

Diseases of the Tympanic Membrane 123 

General Part 123" 

Traumatic Rupture of the Drum Membrane 124 

Scalding and Destruction of the Membrane by Chemicals 128 

LECTURE XV. 

Diseases of the Middle Ear 130 

General Part and Introduction 130 

Occlusion of the Tubes 134 

Its Causes in Diseases of the Nose and the Naso-pharynx. Treatment. . . 134 



CONTENTS x iii 



LECTURE XVI. 

PAGE 

Simple Occlusion of the Tubes and Its Physiological Consequences 144 

Direct Consequences of Occlusion of the Tube 148 

Treatment of Occlusion of the Tubes and Its Consequences 150 

Perpetual Opening of the Tube 154 



LECTURE XVII. 

Acute Inflammation of the Middle Ear 156 

Etiology 156 

Acute and Subacute Simple Inflammation of the Middle Ear without Perfora- 
tion of the Drum Membrane, Otitis Media Simplex Acuta and Subacuta .... 160 



LECTURE XVIII. 

Acute Inflammation of the Middle Ear with Perforation of the Tympanic Mem- 
brane, Otitis Media Purulenta Acuta 167 



LECTURE XIX. 

Empyema of the Mastoid Process in Acute Inflammation of the Middle 

Ear 179 

Mastoid Operation in Acute Inflammation of the Middle Ear 185 

LECTURE XX. 

Chronic Suppurative Inflammation of the Middle Ear, Otitis Media Purulenta 

Chronica 189 

1. Central Perforations 190 

2. Marginal Perforations 191 

A. Chronic Purulent Inflammation of the Middle Ear with Central Per- 

forations of the Tympanic Membrane 197 

Treatment of Otitis Media Purulenta Chronica with Central Perforations.. 198 

LECTURE XXI. 

B. Chronic Purulent Inflammation of the Middle Ear with Marginal Per- 

foration in Schrapnell's Membrane. Cholesteatoma 201 

Treatment of Otitis Media Purulenta Chronica with Marginal Perforation, 205 

LECTURE XXII. 

Suppurative Inflammation of the Middle Ear of Consumptives (Otitis Media 

Purulenta Phthisica). Caries and Necrosis of the Middle Ear 210 

Otitis Media Purulenta of Consumptives 210 

Mastoid Tuberculosis in Children 213 

Tuberculous Fibrinoid of the Middle Ear 214 

Other Forms of Caries and Necrosis of the Middle Ear 215 

Treatment of Otitis Media Purulenta Phthisica, Caries and Necrosis 217 



xiv CONTENTS 



LECTURE XXIII. 

PAGE 

Labyrinthian and Endocranial Complications in Acute and Chronic Suppura- 
tions of the Middle Ear 220 

A. Complications in the Labyrinth. Suppuration and Necrosis of the 

Labyrinth 220 

B. The Endocranial Complications of Acute and Chronic Suppuration of 

the Labyrinth 227 

1. Extradural Gatherings of Pus 227 

LECTURE XXIV. 

2. Sinus Phlebitis 231 

Acute Sepsis 236 

3. Otitic Abscess of the Brain 237 

4. Otitic Leptomeningitis 240 

5. Hysteria in Suppurations of the Middle Ear 242 

LECTURE XXV. 

Residues of Otitis Media Purulenta with Persistent and with Healed Perfora- 
tion of the Tympanic Membrane 243 

A. Dry Persistent Perforation 243 

B. Residues with Closed Perforation 247 

Otitis Media Simplex Chronica. (Chronic Catarrh of the Ear According to 

V. Troeltsch.) 247 

Dysacusis 249 

LECTURE XXVI. 

Otosclerosis 250 

LECTURE XXVII. 

Otalgia 258 

Motor Neurosis of the Middle Ear 259 

New Growths and Formations of Cavities in the Middle Ear 260 

LECTURE XXVIII. 

Diseases of the Inner Ear 264 

General Part 264 

LECTURE XXIX. 

Subjective Noises in the Ears 271 

Degenerative Processes in the Labyrinth 272 

Presbyacusis, Cretinism. Retinitis Pigmentosa 272 

Inflammatory Processes in the Labyrinth 273 

1. Cerebro-spinal Meningitis 273 

2. Syphilis of the Labyrinth : 276 

3. Scarlet fever, Measles and Diphtheria 278 

4. Mumps 279 

5. Other Infectious Diseases 279 

New Formations in the Labyrinth 279 



CONTENTS xv 



LECTURE XXX. 

PAGE 

Affections of the Acoustic Nerve 281 

1. Polyneuritis 281 

2. Degeneration of the Acoustic Nerve on Account of Diseases in Its 

Vicinity 284 

3. Tumors of the Acoustic Nerve 285 

Diseases of the Brain as Causes of Deafness 285 

LECTURE XXXI. 

Hysteria and Traumatic Neurosis of the Acoustic Nerve 289 

Injuries to the Inner Ear 290 

1. Direct Injuries 290 

2. Indirect Injuries 292 

3. Acoustic Traumatisms 294 

4. Electric Traumatisms and Caisson Deafness 295 

LECTURE XXXII. 

Deaf -mutism and Education of Deaf-mutes 296 

Hard Hearing and Diseases of the Ears in Schools 305 



INTRODUCTORY LECTURE. 

Gentlemen : — Only within the last forty years has the special branch 
of medicine that now concerns us been thoroughly investigated and justly 
appreciated as to its manifold and great importance to general medicine. 

We are able to exactly determine the time from which the scientific 
development and the more general valuation of otology date. At the 
very time when the mighty and glorious structure constructed by v. 
Gr'dfe in the modest field of ophthalmology was still dazzling the eyes of 
all, a manual on "otology appeared which, inspired by the results of his 
notable achievement and animated by a like spirit, became also a pioneer 
in a parallel field of medicine. This manual was first published in 1862 
by v. Troltsch and it ran through seven editions up to 1881. It revealed 
lofty stand-points, from which new aims and new roads spread in all 
directions in the domain of otology. In fact, there is hardly a part of 
our branch which v. Troltsch did not enrich with new and fruitful views. 
To the stimulating impulse of this real Book of Instruction, we are in- 
debted first of all for the fact that otologists have since then investi- 
gated their cases from the stand-point of anatomy as well as of physiol- 
ogy, and further that our then little appreciated branch of medicine has 
become the established and scientific department of otology. 

Von Troltsch' s text book was often called the codex of otology and 
it is well for any one who writes a text book to follow its trend of 
thought and its arrangements as much as possible. That is what we 
propose to do. His ingenious work did not become superfluous through 
the great number of text books which appeared since, nor will it through 
this present one, to any one who wants to be informed about the scientific 
development of our branch. 

Otology is important to the general practitioner firstly, because dis- 
eases of the ear occur frequently. Secondly, because suppurations of 
the different spaces of the ear are so common and may so easily invade 
the very important surrounding organs. This explains the comparatively 
high mortality from complications of diseases of the ear. The practi- 
tioner does not sufficiently appreciate these facts. 

All physicians who, as I did, treat diseases of the eye as well as those 
of the ear, find out that very soon the number of ear patients exceeds that 
of eye patients. This may be taken as another illustration of the fre- 
quency of diseases of the ear. 

1 



2 Some Statistics of Deaths from Diseases of the Ear. 

Many diseases of the ear are independent of other affections. A 
large number however are consequences of some general infectious disease. 
Suppurations of the middle ear for example are integral phenomena 
of scarlet fever and measles, as was shown by a large series of post- 
mortem examinations after these children's diseases. The statistics of 
otologists show furthermore that a large number of permanent destruc- 
tions of this organ as well as a considerable number of deaths, in later 
years must be lead back to an early localisation of some general diseases 
in the ear. 

Functional disturbances of this organ are very frequent in old age, 
but even in children and young adults the estimation of v. Troltsch 
may hold good, that on an average one out of every three persons does 
not hear normally well at least in one ear. 

The fact that O. Korner's book on otitic diseases of the brain, 1 the 
meninges and its blood vessels has appeared in its third edition in a 
comparatively short time may be taken as another evidence for the recog- 
nition of the danger to the organism from suppuration of the middle ear. 

My statistics appeared in 1895 regarding 20,468 ear patients, who 
were treated from 1872 to 1892. 2 It shows that 31.8 per cent of all 
ear patients, or nearly one third were treated for suppurations of the 
middle ear or its residues, like perforations or scars of the drum-head. 

Kbrner gives the following figures of death due to suppuration 
from the middle ear : 

In Guy's Hospital out of 9000 post mortems 57 deaths were due 
to suppurations of the ears according to Pitt. Gruber in the Wiener 
Allg. Krankenhaus counted 232 deaths due to ear diseases, among 40073 
post mortems, and Paulson found that 48 deaths were due to ear diseases 
in 14,580 post mortems in the Communal Hospital in Kopenhagen. 

Diseases of the ear were therefore the cause of death in one case 
out of every 158 according to Pitt, of every 232 according to Gruber and 
every 303 according to Paulson of all other diseases combined. 

Barker gives similar figures as Pitt of three other London Hospitals. 

These figures are certainly not too high but rather too low, because 
the pathologist does not examine every ear if his attention is not drawn 
to it, as in cases which were not treated for ear diseases, or which 
were brought to the hospital in an unconscious or dying condition. 
Acute suppurations of the middle ear are most difficult to determine at 
the post-mortem, since they may lead to death without causing perforation 
of the drum membrane and the redness has faded. Or a suppuration 
may have healed and the perforation closed at the time when an endocra- 
nial complication killed the patient. The connection of the cause of death 
with the ear may remain undiscovered not alone in cases of meningitis 



1895. 



*) Bergmann, Wiesbaden 1902. 

8 ) "Ueberschau iiber den gegenwartigen Stand der Ohrenheilkunde." Bergmann, Wiesbaden; 



Sonic Statistics of Deaths from Diseases of the Ear. 3 

and abscess of the brain which were never clinically observed, but also 
in thrombophlebitis and pyaemia when a decomposed thrombus was washed 
away, or when it is located in the bulb of the jugular vein, which region 
is examined only rarely and inadequately. The origin in the ear may 
furthermore be overlooked in the fatal abscesses of gravitation below the 
deep fascia of the neck, in which no perforation of the drum-membrane 
occurred or when for any other reason no competent examination of the 
ear was made. 

The mortality from ear diseases of 33017 patients who were treated 
for their ears amounts to 0.3 per cent according to Bilrkncr who compiled 
the numbers of many authors. 

The author saw 30,336 ear patients from 1881 to 1901 and had 0.2 
per cent deaths due to ear diseases. 

Of 820 patients with suppuration from the ears who were seen in 
the hospital and in the free clinic 2)/ 2 per cent died according to Barker. 

The severe cases which terminate fatally are chiefly met with in hos- 
pitals and therefore we get a more accurate idea if we take also into con- 
sideration those patients who are seen in private practice. The above 
mentioned number of 30336 ear patients, consists of private, free clinic, 
and hospital patients. There were 7273 acute and chronic suppurations 
of which 0.8 per cent were fatal. 

Accurate statistics of Kbrncr, Pitt, Gruber and Paulson demonstrate 
how often each one of the different complications of suppuration of the 
middle ear was fatal. 

If we add up the number of all four authors we find, 

Sinusphlebitis. Abscess of the Brain. Uncomplicated Meningitis. 

164 cases. 123 cases. 136 cases. 

or 38.8 per cent 29.1 per cent 32.1 per cent 

It will be of special interest to find out what part of all the diseases 
of the sinus, of abscesses of the brain and of meningitis are of otitic 
origin. 

Pitt found 56 abscesses of the brain in his 9000 post-mortems. One 
third of them originated in the ears. Treitel gives the same proportion 
in 6000 consecutive post-mortems of the royal "Charite" in Berlin. 

Pitt found in the same 9000 post-mortems 44 cases of sinus phlebitis 
and thrombosis as causes of death, 22 of which were due to diseases of 
the ear. 

One third of all fatal cases of brain abscesses and half of all fatal 
cases of sinusphlebitis and thrombosis are caused by infections of the 
temporal bone according to these figures. Yet Pitt counted also the 
simple marantic thrombosis. If the latter be excluded nearly two thirds 
of all the cases cf sinusplebitis are of otitic origin. 

Leptomeningitis is such a frequent general disease as compared with 
the two other complications of diseases of the ear, that the fatal cases 



4 Some Statistics of Deaths from Diseases of the Ear. 

due to the ear represent only a small fraction of the mortality from men- 
ingitis. 

Males succumb to the above complications about twice as often as 
females ; vthey also suffer much oftener from suppurations of the middle 
ear than females do. 

The otitic diseases of the brain are distributed very irregularly 
through the different periods of life. 

The 246 cases that Komer collected were divided as follows: — 



Age 


Cases 


Per cent 


— 10 years 


44 


17.88 


11 — 20 " 


73 


29.66 


21—30 " 


70 


2745 


3I-40 " 


30 


12.19 


over 40 


29 


11.81 



0.22 


per 


cent 


5.15 


a 




3.85 


(( 




1.44 


" 




0.27 


(( 





Komer basing his calculation of the number of people and their 
mortality upon the Prussian statistics of 1885 calculates from this that 
in every 100 deaths at the age of, 
o — 10 years 
10—20 " 
20—30 " 
30—40 " 
above 40 " 

are due to diseases of the ears. 

4 to 5 per cent of all deaths which occur during the healthiest and 
strongest years of life, that is from 10 to jo years arc due to suppurations 
of the ears according to those statistics of Komer. 

It is therefore evident that the practicing physician ought to be 
versed in the main principles of otology. Firstly, because diseases of the 
ears are not at all rare, and if neglected or incompetently treated may fre- 
quently cause death. Secondly, because the frightful misfortune of par- 
tial or complete loss of hearing viz. impossibility of learning to speak, 
lack of development of the intellect in early childhood, and complete social 
isolation later on in life, can often be averted. 

The time which at present is given to the study of otology, is entirely 
out of proportion to the practical importance and to the vast extent 
which this branch has acquired within the last decades. 

It offers furthermore a great many difficulties which are caused by 
the anatomy and physiology of the organ. 

So many anatomical details are crowded together in the narrow 
space of the temporal bone that every student dreads to be examined 
about them. But whoever wants to work here practically has to know 
also the topographical anatomy of those parts as well as of the neighbor- 
ing organs, the meninges, the brain and the large blood vessels. The 
matter becomes even more complicated from the extreme variability of 



The Requirements of an Otologist. 



the architecture of the organ of hearing and its surroundings, especially 
the arrangement and size of the pneumatic cells of the temporal bone 
and the course and position of the main sinus. 

Our therapeutic actions are mostly of a surgical nature as in most 
of the well developed specialties. But the danger of an incompetent 
operator who does not know the variations is much greater here than 
in any other region. 

The inspection of the drum-membrane which is one of our most 
important means of examination is done through a narrow tube with one 
eye only. We have no perspective view. We see the most important 
changes of the drum-membrane only in extreme perspective fore-shorten- 
ing. It requires therefore years of practice to gain an accurate judgment 
and use the many points gained by the examination, which is equally true 
of the many delicate operations that have to be performed in this way. 

Hearing tests are just as highly developed and therefore equally as 
complicated as the functional tests of the eye. 

We are now able to analyze with the continuous series of tuning- 
forks the very elements of the organ of hearing. We can diagnose 
changes and localize loss of functions in the inner ear just as accurately as 
we can search the fundus of the eye with the ophthalmoscope. 

The continuous series of sounds led us to the deaf-mute institutions and 
made a systematic examination of deaf-mutes possible. We recognized 
that many deaf-mutes have a considerable amount of hearing left which 
they may be taught to make use of for hearing or speaking. For this 
purpose a new method of education was discovered. A new and very 
rich field for work was opened to the ear surgeons in those institutions. 

Gentlemen : You see how much is required of otologists. The time 
allotted the future practicing physician for the study of otology is so 
short that it only suffices to give him a superficial idea of what might be 
accomplished by careful study. 

To make an accurate diagnosis is most important in general prac- 
tice. The house-physician has to determine the time when, in the course 
of the local disease, an invasion of the general organism is threatened 
and operative interference has to take place. 

The treatment of the most frequent local disease is now very simple. 
It can be studied and even tried as to its merits during the time given for 
the purpose. 

The deeper the conscientious physician who wants to devote himself 
to otology, enters into the study of this branch the keener will he feel 
the necessity of practical work as an assistant for several years in some 
special clinic and the^careful study of anatomy, in collections as well as 
from specimens prepared by his own hand. This feeling will be even 
stronger than in other branches of medical science. 



LECTURE II. 

Division of the Organ of Hearing and Topography of the 

Temporal Bone. 

Gentlemen : — The anatomy of the temporal bone is very difficult, so 
much more so since the parts change form and mutual position from 
childhood to old age. Moreover there are great individual variations. 
The topographical anatomy will therefore be a main point of our general 
considerations. 

We will start with a general survey of the organ of hearing. 

As to the physiological function we recognize a sound conducting 
and a sound perceiving apparatus. 

The sound conducting apparatus consists of the concha and the 
external canal which act as receivers of sound. Secondly of the real 
sound conducting apparatus, the drum-head and the chain of ossicles 
including the foot plate of the stirrup with the ligamentum annulare. 

The sound perceiving apparatus consists firstly of the labyrinth which 
contains the terminal distributions of the acoustic nerve. Secondly the 
acoustic nerve with its nuclei in the medulla oblongata, the acoustic tracts 
in the brain and the acoustic centers of the cortex of the first and second 
convolution of the temporal lobe on both sides. 

As you know from physiology, the labyrinth contains besides the 
cochlea, which, according to our present views has exclusively the function 
of hearing, another organ which serves to maintain the equilibrium. It 
has its terminal apparatus in the vestibulum and the semicircular canals. 
It has its own nerve fibers which are separated from the others through- 
out. 

The part of the organ of hearing which is included in the temporal 
bone, consists of three systems of bone cavities which are separated from 
each other partly by membranous partitions. They are called the external 
car, the middle and the inner ear. Each part having its own diseases. 
we speak about diseases of the external ear, of the middle and of inner ear. 

The different parts of the external ear are the concha, the external 
auditory canal and the drum-head which forms the bottom of the glove- 
finger of cutis of the external meatus. It takes part in its diseases. 

6 



The Topography of the Ear. 



The drum-cavity is the main cavity of the middle ear. It has the 
shape of a low cylinder or a flat box directly inside of the drum-head. 
The top and bottom of it are the large external and inner wall (compare 
fig. i and 2). The external wall is the drum-head, which is funnel shaped. 




Figs. 1 and 2. Vertical cut in the axis of the tube and through the other 
main spaces of the middle ear. Fig. 1 showing the outer surface of the cut, 
presenting the inner surface of the drum-membrane. Fig. 2 showing the inner 
surface of tne cut containing the promontory in the drum-cavity (according 
to Siebenmann). 

a drum-cavity, 6 aditus ad antrum (containing in Fig. 1 the bodies of the hammer and incus), 
c antrum, d cells of the mastoid process, e ostium tympanicum of the tube, / ostium pharyngeum 
of the tube, g isthmus of the tube, h tendon of the tensor tympani muscle (in Fig. 2 it is cut), 
i pneumatic cells of the aditus ad antrum, k pneumatic cells in the floor of the tube, / prominence 
containing the facial nerve, m stapes in the niche of the oval window, n tendon of the stapedius 
muscle. 

The interior wall is the promontory which separates it from the labyrinth. 
Both the drum-head and the promontory protrude into the middle ear 
and therefore come very close together in the middle of the cavity. The 
circumference is a low, trabeculated bony wall with many little holes. 
This wall is absent in two places. The first gap is the ostium tympani- 
cum of the Eustachian tube, which begins at the upper part of the ante- 



8 The Topography of the External Ear and Middle Ear. 

rior circumference, and runs in a straight line from the rear, upward and 
outward, forward, downward, and inward to the lateral wall of the naso- 
pharynx, where its opening is called the ostium pharyngeum of the tube. 
The second gap is much larger. It is on the rear part of the upper cir- 
cumference and leads through the aditus ad antrum into the antrum 
mastoideum, which is the main cell in the mastoid process. 

A cast of the aditus and antrum has about the form of a three 
sided prism (fig. 3-4, a). The upper surface is the bony tegmen 
tympani et antri. The anterior part of this prism contains the bodies of 
the hammer and anvil. The handle of the hammer and the long process 
of the anvil are in the drum-cavity. The short process of the anvil rests 
with its point in the edge of the prism. We begin the aditus ad antrum 
from that piece of the protruding horizontal part of the canal for the facial 
nerve which lies directly above the oval window. The two liminal stands 




Fig. 3. Fig. 4. 

Figs. 3 and 4. Cast of the main spaces of the middle-ear. Corrosion speci- 
men, the soft tissues were not previously removed. Fig. 3 as seen from the 
outside, Fig. 4 from the inside. 

a the tube, b druru-cavity, c aditus ad antrum, d antrum. 

of the drum-head are laterally just opposite it. An isthmus is formed 
there by the protrusion of the Fallopian canal which is so much narrower 
on account of the ossicles. Natural limits are thus fixed between the 
low cylinder of the drum-cavity and the prismatic space of the aditus 
(comp. fig. 4.). The greater number of authors add the anterior part of 
the aditus, as we just described it, to the drum-cavity and call it the upper 
part of the drum-cavity, or the cupola, the recessus epitympanicus or the 
attic. They have to describe besides an aditus ad antrum. The descrip- 
tion which was just given seems to be considerably more simple and 
more accurate as to forms. It is all the more justifiable in that the dis- 
eases above the isthmus are different from those of the drum-cavity and 
require a different treatment. 

The antrum mastoideum is the enlargement of the aditus in the rear. 
It has the form and size of a bean the hilus of which is turned down. 
This cavity in the new born has nearly the same size as in adults and may 



The Topography of the External Ear and Middle Ear. 9 

be found as a cavity almost constantly at our frequent operations, years 
of serious suppurations of the bone notwithstanding. 

Fig. 5 representing a cast of the main cavities shows that the drum-cav- 
ity, the aditus and the antrum lie approximately in the continuation of the 
axis of the tube. The external meatus forms with it a very obtuse angle 
downward and outward. 

This is the main tract of cavities of the middle-ear which is con- 
stantly present. A system of pneumatic cells is in connection with it. 
These cells vary extremely in size and number. 

The main group of these cells start from the mastoid antrum. Like 
the branches of a tree they have generally a radial direction. They are 
narrow near the antrum and become wider towards the periphery. They 




Fig. 5. 

Cast of the main spaces of the middle ear in connection with the external 
canal and the auricle. The first intermediary cells emanating from the antrum 
are also seen. Corrosion specimen, the soft tissues and skin were not previously 
removed. 

terminate in large ball shaped cavities which are on an average larger 
the further they are away from the antrum. The first ones are interme- 
diary cells, the last terminal cells. Fig. 6 gives you an idea of the 
arrangement of this system of cells. 

A second, much smaller system of cells starts from the floor of the 
drum-cavity and the bony tube. It is often absent and is homologous to 
the bulla ossea of mammals. The author never found a communication of 
these cells with the large ones starting from the antrum. 

The cells starting from the antrum are almost exclusively responsible 
for the propagation of suppurations of the middle-ear, which lead to seri- 
ous complications. 

We shall therefore give a more complete description of them: 



10 The Topography of the Middle Ear. 

The new born babe has neither a mastoid process nor cells. At the 
age of one year we find little off-shoots from the circumference of the 
antrum and at six years we find almost completely developed systems of 
cells. 

The number, size and distribution of the mastoid cells of the adult 
vary with each individual. 

The cut of a cast of the soft parts (fig. 6) gives you only a very 
inadequate idea of the real extent of the cells over the temporal bone, 
because the greater number of peripheral cells do not fill up with the sub- 
stance, or because they break off later on in the course of the preparation. 

We get a very good idea of all the cavities, if we place a well mace- 
rated temporal bone into boiling corrosion mass, which drives out all the 
air. In this way faultless casts can be made of the two systems of cells 




Cast of the spaces of the middle ear seen from within. The soft tissues were 

not previously removed. 

a drum-cavity, b ostium tympanicum of the tube, c ostium pharyngeum of the tube, d aditus 
ad antrum, e antrum mastoideum, / cells of the mastoid process, g cells on the floor of the drum- 
cavity. 

as well as of the labyrinth, the aquaeducts, the porus acusticus int., the 
facial nerve, the canal of the chorda tympani, the carotid artery, the sig- 
moid sinus and the bulb of the jugular vein. The cells which emanate 
from the antrum are lined with a very thin mucous membrane and there- 
fore their form is the same whether the mucous membrane is in or not. 

From such a cast of the temporal bone we are able to form a general 
idea of the topography of the cells and their neighborhood (fig. 7-8). 

We ought to study not only one, but a number of such specimens 
in order to become acquainted with all possible ways by which suppura- 
tive processes of the middle ear may reach surrounding organs. I have 
shown a series of cuts in my "Corrosion Anatomy of the Ear." (Munich 
Theoder Riedel, 1882 Literar, artist institution) which show how the 
number, size and distribution of the cells vary, as do also the size and 



The Topography of the Middle Ear. 11 

form of the adjoining organs, especially the sinus and the bulb of the 
jugular vein, which become infected most often. 

In examining a collection of such casts you will find that wherever 
the cells are well developed, they show an almost perfect image of the 
forms of the temporal bone, though a trifle diminished in size. The 
cells penetrate everywhere, with the exception of the squamous part ano 
the anterior wall of the meatus. You will recognize the mastoid proces- 
sus with the incisura mastoidea. The cells may spread even medially of 
the latter, along the base of the temporal bone to the bulb of the jugular 
vein which they often partly overlap. Starting from the base of the mas- 
toid process they surround the whole external canal with the exception 
of its anterior wall and fill the entire root of the zygomatic process as 
far as the crista temporalis. Towards the interior they extend into the 
pyramid and surround the labyrinth on all sides. Flat cells may partly 
surround the carotid canal. The sigmoid sinus is often directly sur- 
rounded by cells, which may reach to the rear far beyond it, into the 
occipital bone. 

The thinnest part which may even have dehiscencies is the upper wall 
of the flat cells enclosed in the tegmen tympani and antri. The cells 
which surround the sigmoid sinus are often also transparent toward the 
sulcus. A third very thin portion of the wall is at the bottom of the tem- 
poral bone on either side of the incisura mastoidea. 

The largest cells, as stated before, lie in the periphery. We find them 
in the point of the mastoid process, behind the sinus and on top of it, in 
the vicinity of the crista temporalis, in the point of the pyramid. One 
or more especially large cells are often found on either side of the incis- 
ura mastoidea and towards the bulbus (fig. 8). 

These large cells in the different regions of the temporal bone are 
especially important in the propagation of the suppurative processes. In 
locating the three thinnest portions of the cellular walls we have ascer- 
tained the spots where suppurations of the middle ear most frequently 
perforate, inwardly and outwardly. 

Fig. 7-8 show casts of temporal bones with perfectly developed sys- 
tems of cells. 

Fig. 9 on the other hand shows a cast of a temporal bone of an adult 
in which, with the exception of the antrum all the cells are wanting. 

The latter specimen is especially instructive in studying the relative 
position of the outer meatus and the sigmoid sinus. In order to open the 
antrum mastoideum at an operation we have to pass between the two. 
You perceive the cast of the antrum lying in the depth between the meatus 
and sinus. The cast of the facial canal runs perpendicularly downward 
on the inside of the antrum. Thus in this specimen you have a perfect 
survey, which shows how to avoid injuring the sinus or the facial 
nerve in opening the antrum. 



12 



The Topography of the Middle Ear. 



In order to attain an exact conception of the great variety of the 
cellular formations in the temporal bone you must remember that between 
the extremes of perfect formation on one hand and the absolute absence 




Cast of the cavities of the temporal bone, seen from outside, obtained by corrosion, 
all soft tissues being previously removed. 

a external meatus, b fossa digastrica (incisura mastoidea), c bony part of the tube, d bulbus 
of the internal jugular vein, e sulcus sigmoid eus, f canal of the carotid artery, q terminal cells 
in the point of the mastoid process, h terminal cells medial of the incisura mastoidea, i terminal 
cells on top of the sigmoid sinus, A; terminal cells below the crista temporalis, I cells on the floor 
of the drum cavity, to a cell in the floor of the tube. 




£ 



Fig. 8. 
Cast of the temporal bone seen from inside. 



a poms acusticus internus, b cochlea, c semicircular canals, d ductus subarcuatus, e sinus sig- 
moideus, / emissarium mastoideum (vein) g canal of the carotid artery, h fossa digastrica, i ter- 
minal cells of the mastoid process, k cells surrounding the emissar mast, I cells surrounding the 
labyrinth. 

of pneumatic cells on the other, we find all degrees imaginable, if we will 
but examine a great number of casts. 

I must take it for granted that the shape of the three ossicles of the 
ear is known to you, also their connection with each other and the tensor 



The Topography of the Labyrinth. 13 

tympani and stapedius muscles, as well as that of the foot-plate of the 
stirrup with the oval window. 

A few points must be mentioned as to topography. Examining a 
macerated temporal through the external canal you will find that the 
oval window is usually partly covered by the posterior upper part of the 
bony frame of the drum-head. A different view presents itself, when the 
ossicles are preserved. You then see the lower part of the long process 
of the anvil extending upward and backward in a vertical direction. 
Close to its end the anterior part of the tendon of the stapedius muscle 
runs horizontally backwards. You see furthermore the profile of the 
entrance of the niche of the round window in the posterior lower quad- 
rant. It forms the posterior edge of the smooth promontory. A direct 
injury to the membrane of the round window, which is hidden in the 
depth of the niche, is therefore impossible. 




Fig. 9. 

Cast of an adult with very rudimentary development of the cells. The soft 
tissues were previously removed. 

a external canal, b tube, c pneumatic cells in the floor of the tube, e rudimentary cells in con- 
nection with the antrum, f sulcus sigmoideus, g emissarium mastoideum, h canalis Fallopiae 
(facial nerve;, i canal of the carotid artery, k bridge of corrosion mass. 

A knowledge of the general form of the labyrinth and its contents 
must be taken for granted. 

Looking at the median wall of the middle ear you see the promi- 
nence of the horizontal semicircular canal in the aditus running directly 
above and parallel to the elevation of the canal for the facial nerve 
which has here a horizontal direction. The basal whorl of the cochlea 
runs horizontally forward from the round window within the promon- 
tory. The cupola of the cochlea rests against the tympanic end of the 
osseous Eustachian tube. 

The membranous labyrinth is entirely enclosed in the bony labyrinth. 
It contains the endolymphatic space, which has no communication with 
the outside. It is surrounded by the perilymphatic space, which is much 
larger and also enclosed in the bony labyrinth. The scala tympani and 
the scala vestibuli in the cochlea are parts of the perilymphatic space. 
The endolymphatic space is enclosed in the ductus spiralis which has 



14 The Manometric Tests of the Labyrinth. 

three sides and contains the organ of Corti. The continuation of the 
perilymphatic space in the vestibulum is the cysterna perilymphatica 
(Steinbrilgge) which is rather wide and lies between the foot-plate of the 
stirrup and two small sacs in the vestibulum. The form of the membra- 
neous labyrinth is simply a somewhat smaller reproduction of the bony 
labyrinth, to the inner walls of which it is everywhere attached. 

Both the perilymphatic and the endolymphatic spaces communicate 
with the cranial cavity. The aquaeductus cochleae leads directly into the 
subarachnoidal space from the base of the scala tympani through an 
opening in the floor of the temporal bone. The aquaeductus vestibuli, 
which starts from the sacculus and utriculus, communicates with a large 
flat bag through a slit-like opening in the posterior surface of the pyra- 
mid of the temporal bone. This bag extends across the sigmoid sinus 
and is between two layers of the dura, which is split for that purpose.. 
This saccus endolymphaticus is connected with the system of lymph- 
vessels of the dura. 

We can observe the pathological increase of the intraocular pressure 
and its serious consequences for the function of the eye. A similar 
increase of pressure in the labyrinth was described as a cause of disease 
of the end organs of the acoustic nerve. 

I succeeded in proving by the following experiments on fresh tempo- 
ral bones that both aquaeducts are very patulous for the labyrinthine 
fluid: 

The upper semicircular canal was opened at its highest point. In the 
opening a capillary tube which contained some colored fluid was hermet- 
ically inserted, so that its fluid was a continuation of the labyrinthine 
fluid. The fluid in the glass tube acts as a manometer, and rises several 
centimeters if we press with our finger against the saccus endolymphat- 
icus on the posterior surface of the pyramid of the temporal bone. The 
same thing occurs if we press the finger tightly against the opening of 
the aquaeductus cochleae at the floor of the temporal bone. In several 
cases I saw the colored fluid which in this way was inserted into the 
upper semicircular canal drop out of the aquaeductus cochleae. Finally 
we succeed in causing the fluid to rise in the manometer tube, when we 
press our finger hard upon the porus acusticus internus. This is 
explained by the transmission of pressure through the rich supply of 
blood vessels of the lamina cribrosa. 

It is evident that on all sides there is a free communication of the 
labyrinth with the interior of the skull. It is therefore impossible that 
a local increase of pressure in the labyrinth can occur and last long 
enough to cause all those diseases which were attributed to it. 

The free communication between the spaces of the labyrinth and the 
skull will attract our interest for another reason, which we shall enter 
into more minutely in the special part. We will recognize the great 



The Facial Nerve and the Internal Carotid Artery. 15 

danger which threatens the whole organism when the pus of an inflamma- 
tion of the middle ear perforates into the labyrinth. 

I explained the experiments with the manometer of the labyrinth for 
another purpose. They enable us to study as Politzer and v. HelmholtZ 
did before me the movement of the sound conducting apparatus of the 
windows of the labyrinth. We see the fluid in the manometer rise and fall 
when we compress or rarify the air in the external auditory meatus. 
This is due to the inward and outward movement of the foot plate of the 
stirrup. The rise and fall of the fluid in the manometer is five times as 
large if we compress and aspirate the air of the middle ear through the 
Eustachian tube than through the external meatus, because the movement 
is transmitted through the flabby membrane of the round window. Start- 
ing from these observations we will learn to understand the physiological 
function of the sound conducting apparatus. 

After this little deviation from our subject let us return to the topog- 
raphy of the ear. You know that the facial nerve runs mostly on the 
inside of the temporal bone. Its path leads backward directly above the 
cochlea laterally along the whole osseous labyrinth. Its canal forms a 
horizontal protuberance on the inner wall of the aditus ad antrum, just 
above the oval window. The thin wall of this canal is often perforated. 
About three millimeters to the rear and medial of the sulcus of the drum- 
head, the horizontal course of the nerve changes into a vertical one, 
downward through the main part of the pars mastoidea to the foramen 
stylo-mastoideum. The whole course gives ample explanation for the 
frequent injuries to this nerve in destructive diseases of the bone, both 
of the middle and inner ear. 

Pus from suppuration of the middle ear may travel along the canal 
and invade the skull cavity through the porus acusticus internus. 

The internal carotid artery also is in close proximity to the anterior 
wall of the drum-cavity and to the bony wall of the tube. A number of 
cases are described in literature where a fatal hemorrhage from the ear 
and tube was caused by necrosis or injury of the temporal bone. 

The close proximity of the spaces of the middle ear and the trans- 
verse sinus and jugular bulb, are finally of great practical importance. 
The "S" shaped vertical part of the sinus descends along the inner sur- 
face of the pars mastoidea. The posterior end of the antrum is often 
divided from it by a thin bony partition only. (Fig. 16 c.) Pneumatic 
cells of different dimensions may be found all along the sinus and jugular 
bulb. The main point is the extreme variability in size and position of 
this largest sinus, through which passes the greater part of the venous 
blood from the interior of the skull. The right sinus and its bulbus is 
usually larger than the left one. The arch of the sinus may be advanced 
so far forward and outward that its groove seems to have dug out the 
whole base of the pyramid from the rear. The bony wall between the 
groove and the external meatus as well as the outside of the pars mas- 



16 



The Sigmoid Sinus. 




Fig. 12. 
Figs. 10 to 12 are horizontal cuts of the temporal bone through the spina 
supra meatum (a) showing different development of the sigmoid sinus. Fig. 10 
shows a moderately well, Fig. 11a well, Fig. 12 a very well developed groove for 
the sigmoid sinus. 



The Bulbus of the Jugular Vein. 17 

toidea in such cases may be very thin and transparent. The bony wall 
between the jugular bulb and the floor of the drum-cavity may either con- 
tain pneumatic cells or may be extremely thin. It may even be wanting 
altogether to a large extent, so that the bulb protrudes into the drum- 
cavity, and in making a paracentesis of the drum-head it was repeatedly 
cut open. In some rare cases the bulbus forms the floor of the bony 
meatus and may take the place of the bone of the innermost part of the 
canal. 

You will see the great difference in size and position of the sinus 
by the three horizontal cuts through the spina suprameatum of the tem- 
poral bone. In very rare cases the anterior wall of the drum-cavity is 
wanting, in which cases the internal carotid artery is exposed. 

You have to be thoroughly acquainted with all these variations of 
form if you want to accurately judge of the frequent involvement of the 
sinus in suppurations of the middle ear. Operations on these parts very 
often become necessary and great damage may be done. 

You will easily recognize that there is hardly another part of the 
body which calls for higher qualifications on the part of the operator as 
to anatomical knowledge than the temporal bone. 



LECTURE III. 
Methods of Examination of the Ear. 

Gentlemen: — Otology was considered up to our days by the majority 
of physicians as one of the most unsatisfactory branches of medicine. 

Our therapeutical results in such a limited area depend first upon 
the question : in how far can we control it with our methods of examina- 
tion ? and next, in how far can we enter into it surgically ? 

Considering the organ of hearing from this point of view, we find 
that there are three avenues by which we can reach those spaces for ex- 
amination and operation. 

Under normal conditions we are able to examine the walls of the 
outer canal and the outside of the drumhead, up to its periphery with a 
perforated reflector. The reflector was introduced by v. Troeltsch. 
The color and form of the drum-membrane are extremely changeable, on 
account of its partial transparency and easy mobility. From changes of 
the drum-head we are able to draw conclusions as to changes in the mid- 
dle ear often to its most remote parts even up to the pharyngeal end of 
the eustachian tube. 

We can see into the drum-cavity if there is a perforation in the 
drum-head. With the reflector as our guide we can perform a number of 
operations either through an already existing hole in the drum-membrane 
or after we have excised a part of it ; they are, removal of polyps, tenot- 
omies, extraction of ossicles, and so forth. 

Destructions of bone at the upper pole of the drum-membrane which 
may extend far into the bony meatus are comparatively frequent occur- 
rences. They allow us to inspect and treat large parts of the aditus and 
antrum. 

The second avenue by which to reach the middle ear is through the 
eustachian tube. Its pharyngeal opening is hidden in the naso-pharynx, 
but we can reach it through the eustachian catheter. 

Many different methods of treatment through this avenue were tried 
and partially abandoned, as for example the direct introduction of vapors 
and fluids into the middle ear, the use of bougies, massage, galvanolysis, 
etc., etc. 

18 



The Examination Through the Tube. 19 



Inflation by means of compressed air through the catheter and tube 
is by far the most important method of treatment. We are able in this 
way to open the tube artificially when it is not patulous, to fill the different 
parts of the middle ear with air, and to remove secretions at least to 
some extent. At the same time we succeed in bringing the sound con- 
ducting apparatus back to its normal position and mobility. 

Politzer in 1863 introduced the air douche without the catheter, and 
thereby connected his name forever with the development of otology. 
He put us in a position to open up the tube in those cases, in which the 
use of the catheter is impossible, as for example in children, who have 
a great tendency towards inflammations of the middle ear and therefore 
heed the air douche so often. By Politzer's method alone the greater 
number of ear diseases of childhood became curable and a large number 
of diseases which later on might have been deleterious could be prevented. 

The third avenue by which we may reach the diseased spaces of the 
middle ear is by operation. 

Schwartze and his assistant Eysell published a paper in the Archiv 
F. O. in 1873 concerning the operation of the mastoid process. Bad ex- 
periences at the end of the 18th century had created a general dread of 
this operation amongst surgeons and otologists which lasted for many 
decades. At that time it was done without sufficient anatomical knowl- 
edge, with inaccurate indications and poor technic, reasons enough for 
the fact that it was often fatal. Schwartze pointed out all these short- 
comings and, by means of his bold surgical procedure did away with all 
prejudice against opening the middle ear. 

Since we learned to open the middle ear, we have found out how 
often suppurations occur in distant locations. By and by we even fol- 
lowed up and successfully operated the serious complications which 
are caused by progression of the suppuration in the vicinity of the ear, 
for instance in the meninges, sigmoid sinus and brain, which so often en- 
danger life. It is impossible to estimate the number of cases which only a 
few decades ago were incurable and which now are cured within a few 
weeks or months' by operative procedures. Complications which may 
endanger life are now nearly excluded if treatment follows the well-es- 
tablished rules, and operation, when necessary, is not postponed too long. 
Even in very neglected cases where thrombophlebitis with septicopyemia 
or abscess of the brain has already set in, an operation may be successful. 
Finally there is no question but that death from diseases of the ears will 
be reduced to a minimum when the present too great operative enthus- 
iasm, which is explained easily enough, is reduced to its proper limits. 

These few remarks may suffice to show you that otology, as concerns 
its lasting results, is really one of the most fertile branches of medicine. 

You heard that there are three avenues by which the ear may be 
reached for examination and treatment. For practical reasons I want to 
talk to you first about the second one, that of the eustachian tube, be- 



20 The Anatomy of the Eustachian Tube. 

cause I want you to have a chance to use the catheter as often as possible 
while we are together. This little manipulation requires a good deal of 
practice. We often find out only after years of experience that we might 
have succeeded almost without causing any pain in cases which in the 
beginning offered insurmountable difficulties. 

The best way to introduce the catheter is as a rule through the lower 
nasal meatus (fig. 13). The ostium of the tube lies in the prolon- 
gation of the lower turbinal, a little more than 1 centimeter from its rear 
end in the side wall of the naso-pharynx. Its upper and rear limit is the 
protruding cartilage, which gives it the shape of a Roman tube. The 
anterior and lateral parts of the circumference are membranous. A 
groove, called Rosenmiiller's fossa runs around the rear and upper parts, i. 
e., around the cartilage. The vault of the naso-pharynx is lined with 
glandular tissue which is similar to the tonsils. This tissue is often de- 
veloped to such an extent, especially in children, that it forms a regular 
tonsil with a middle and two side folds (compare fig. 55). The tissue 
of this naso-pharyngeal tonsil often extends somewhat over the rear wall 
of the naso-pharynx and into Rosenmiiller's fossa. 

This naso-pharyngeal tonsil becomes hypertrophic in children at 
least as often as the faucial tonsils. It then becomes a cause for disease 
of the middle ear either through occlusion of the tube or through pro- 
gress of its inflammations along the tube. 

The floor of the naso-pharynx is the soft palate which acts like a 
trap door. It is closed only during the act of swallowing and phonation, 
when it rises into the naso-pharynx like a cupola. At the same time the 
openings of the tubes together with all the soft tissues of the rear wall, 
protrude so that the catheter during the act of swallowing is often held 
so tightly that it cannot be moved. 

The eustachian tube, the anatomy of which we have to study on ac- 
count of its importance for physiology and pathogenesis of the ear, is a 
nearly straight tube about 36 millimeters long (compare fig. 3 to 5, pages 
8, 9). Not quite one-third of its length nearest the drum-cavity has 
bony walls, and its cross section is triangular. The remainder is car- 
tilaginous and slit-shaped. It becomes wider towards the naso-pharynx, 
and its opening is about nine millimeters in length. The upper part of 
the cartilaginous tube is the narrowest, called the isthmus. Here the slit 
: is only three millimeters high on an average. The median and lateral wall 
of the tube touch, so that in trying to fill it for casts the cartilaginous 
tube fills only exceptionally. In cuts of frozen specimens also, this part of 
the tube is found closed. Successful casts therefore present the tube 
while it is opened. 

The tube at the isthmus often shows a slight curve, and its axis is 
somewhat twisted. These are the reasons why it is often impossible to in- 
sert a bougie through the normal tube without interference, as I became 
convinced from experiments on the cadaver. We are therefore not justi- 



The Anatomy of the Eustachian Tube. 



21 



fied in drawing the conclusion that there is a stricture of the isthmus in the 
living, from the fact that we do not succeed in inserting a bougie. In fact 
in all my very numerous post mortems I never found a stricture there. 

The cartilaginous tube in children is shorter, in proportion to the bony 
tube, than in adults. The membranous part of the lateral wall is more 
developed and the isthmus is wider. All these points cause the tube to 
open more easily in children. The pharyngeal end in children does not 
protrude so much as in adults nor is it so much wider than the rest of 




Fig. 13. 

Sagittal cut through the skull, the septum of the nose is removed and a catheter 

is inserted into the tube. 



the tube as is the case in adults. It is a simple slit. Consequently oc- 
clusion of the tubes occurs much more easily in children than in adults, 
if the mucous membrane of the entrance and its neighborhood is swol- 
len. The ostium of the tube in children is on a level with the bony palate 
and only later rises up to the level of the turbinal. 

The mucous membrane of the tubes is a direct continuation of that 
of the naso-pharynx. It is lined with a layer of high ciliated epithelium. 
The constant movement of the cilia is justly considered a protection 
against the advance of infection in the tube. 

A layer of adenoid tissue is immediately below the epithelium of the 
cartilaginous tube. It is a continuation of Waldyer's adenoid ring. It 
has crypts and follicles which are especially well developed in children 



22 



The Physiology of the Tube. 



and a frequent cause for occlusion of the tube. The submucous tissue 
contains a great many mucous glands of the alveolar variety. The open- 
ings of these glands are especially numerous about the ostium of the 
tube. The adenoid tissue and the mucous glands decrease towards 
the isthmus. In the bony part of the tube there is no adenoid tissue and 
only few mucous glands (Siebenmann) . There the ciliated epithelium is 
lower in type and the mucous membrane merges into the periosteum of the 
drum-cavity and the rest of the middle ear. Experience shows that the 
mucous membrane of the pharyngeal opening and the cartilaginous tube 
participates largely in diseases of the naso-pharynx. The bony tube is 
affected when there is hyperaemia and swelling of the mucous mem- 
brane of the drum-cavity. The isthmus and the middle part of the tube 
are the most rarely and least affected by pathologic changes. 




a 

Fig. 14. 

Perpendicular cut through both tubes (according to Riidinger). 

a posterior wall of the naso-pharynx, b cartilaginous tube, c ostium tympanicum of the tube, 
d sphenoidal sinuses, e M tensor veli, / M levator veli, g M tensor tympani, h meatus auditorius 
externus. 

The tube is closed as a rule. It opens actively in swallowing and 
yawning by means of two muscles which have their insertion in the soft 
palate. 

The first one, the Muse, spheno-salpingo staphylinus, or muse, tensor 
veli arises partly from the spina angularis and the pterygoid process of 
the sphenoid bone. A large part of its fibres arise from the exterior 
and lower surface of the cartilage of the tube, the cross section of which 
has here the shape of a hook, and also from membranous parts of the 
wall of the tube which fills the gap of the cartilage. (Compare fig. 14 
and fig. 55). 

The muscle starts fanshaped downward from the outside wall of the 
tube in an acute angle with the tube and forms a tendon which turns 
around the hamulus of the pterygoid bone. Further on, the fibers spread 



The Physiology of the Eustachian Tube. 23 

again and form a tendinous plate with those from the opposite side which 
is attached to the hard palate. Some of the fibers of the tendon are at- 
tached to the hamulus where they find an immovable point, which is 
much steadier when the soft palate is stretched out by the glosso- and 
pharyngo-palate muscles, as in swallowing. The fanshaped upper part of 
the muscle pulls at the lateral hook of the tube and acts therefore as an 
abductor of the membranous lateral wall of the tube. (Riidinger.) 

The second muscle which helps to open the tube is the petrosalpingo- 
staphylinus or levator of the palate. It starts from the lower surface of 
the temporal bone near the entrance to the carotid canal. From there its 
cylindrical belly runs along the floor of the cartilaginous tube. It is 
separated from the abductor of the tube by the fascia salpingo-pharyn- 
gea which runs downward from the tube. Its fanshaped end is inserted 
in the soft palate. 

Sometimes we are able to see the opening of the tube by means of 
anterior rhinoscopy, as when the lower turbinal is deficient. The belly 
of the contracting levator muscle can be seen rising from the floor in 
front of the entrance of the tube. It appears as though it might compress 
the lumen, but its pressure on the slit in the direction of its axis, together 
with the action of abductor results in a round opening. 

The protrusion of the opening of the tube into the naso-pharynx in 
swallowing is the effect of the salpingo pharyngeus muscle, called re- 
trahens tubae, which is a continuation of the palato pharyngeus muscle. 

We can convince ourselves by means of an auscultation tube that the 
tube opens in swallowing. A current of air which is directed into the 
tube can be heard much louder during the act of swallowing. It can be 
heard during that moment only if there is a partial occlusion of the tube. 

Furthermore a sounding tuning fork held in front of the nose can 
be heard again during the act of swallowing after it has ceased to be 
heard otherwise. 

Many people are able to open their tubes at will, and keep them open 
for some time. All nasal consonants like M. and N. and also the nasal 
vowels which are pronounced by the experimenter during this action, 
sound very strongly, and disagreeably. Everybody can notice the same 
increase of sound in yawning. It is called autophonia. 

This shows that the occlusion of the tube in repose is necessary for 
protection against entrance of infection and foreign bodies as well as for 
the normal function of the sound conducting apparatus. There is a path- 
ologic condition where the tube is wider than normal and is continually 
open. We hear from such patients how disagreeably the continuous au- 
tophonia feels. 

We shall learn in the chapter about etiology of diseases of the tubes 
of what importance a temporary opening of the tube is for the ventilation 
of all the spaces of the middle ear. 

The insertion of the catheter through the lower nasal meatus would be 



24 The Anatomical Variations in the Nasal Cavity. 

a very easy procedure under normal conditions. A symmetrical form of 
both sides of the nose is however not the rule, but rather the exception. 
Generally one side of the nose, in most cases the left side, is narrower 
than the other. This narrowness is caused by some irregularity of the 
septum, which may be located either in the bony septum or in the car- 
tilage or in both. The vomer may have edges or ridges. The cartilag- 
inous part of the septum may be so deformed as to be visible in either nos- 
tril like a tumor. The most frequent deformity is, where the vomer and 
the quadrangular cartilage together form a long ridge which protrudes 
into either side. 

The cartilage and often the bone too, is thickened so that the ridge 
protrudes into one, and often both sides. Some times these ridges and 
deviations of the septum come far to the front. Near the entrance of 
the nose they come close to the floor of the nose, so that even the expert 
is unable to insert a catheter. Rarely an abnormally low inferior tur- 
binal and still more rarely irregularities of the floor of the nose block 
the way. A few more pathological changes that may interfere are polyps, 
large diffuse hypertrophies, stalactite shaped crusts in ozaena, etc. The 
removal of these different obstructions will always be an important part 
of our therapy. 



LECTURE IV. 
Examination through the Tube. 

Gentlemen : Before entering into a description of the technic of the 
insertion of the catheter I have to mention a few accidents which may oc- 
cur thereby. An extensive swelling of the cheek and side of the neck 
may suddenly appear while forcing air into the catheter, if the same was 
awkwardly or forcibly inserted, or if a whale-bone or celluloid probe was 
previously passed through it. The patient then usually grasps the hand 
of the operator or pulls out the catheter. An examination of the naso- 
pharynx shows that the rear and side wall and the soft palate are bloated. 
You feel the crepitus of the escaping air bubbles when you touch the cheek 
or neck. A subcutaneous and submucous emphysema zcas caused by the 
inflation through the catheter. This can hardly be explained otherwise 
than that the catheter or the probe bored a new road into the submucous 
tissue. We shall see later in talking about the technic of catheterisation 
how easily such an injury may occur. 

That is probably also the explanation of two deaths during catheteri- 
sation which were reported in the beginning of the past century by Turn- 
bull of London. The patient had been entrusted to charge an air tank which 
was used for forcing the air through the catheter. The emphysema, on 
account of high pressure, probably spread over the entrance of the larynx 
and caused death from suffocation. We now use a single or double bulb 
for the compression of air, which will hardly produce high enough 
pressure to cause an emphysema of that extent. 

The first attempt of students at introduction of the catheter must be 
personally guided by the director in every clinic. I have not seen a case of 
emphysema in many years since that rule was accepted. Should such an 
accident occur, a dressing which compresses the parts for the next few 
days will cure the emphysema. It may however become necessary to 
make a few small incisions with a pair of scissors to relieve the swelling 
of the soft palate. 

There is much greater danger of carrying infections from one patient 
to another by means of the catheter. A number of cases of primary 

25 



26 The Technic of Inserting a Catheter into the Tube. 

syphilitic affections in the naso-pharynx caused by insufficiently cleaned 
catheters are recorded in the otological literature. The secondary affec- 
tions in all those cases were particularly serious. The same minute clean- 
liness and asepsis must be observed in otological as in other surgical in- 
struments. The catheter must be boiled in a solution of wash soda or 5% 
carbolic acid after a careful mechanical cleaning. It ought to be kept 
where no new infection can reach it. 

We use silver catheters of three different curvatures of the beak. 
The aperture may be equally wide in all, about 2.5 millimeters. A hard 
rubber catheter which can be bent into different shapes after it has lain 
in boiling water, may be used when such is required. 

There are different methods in the technic of inserting a catheter. It 
is expedient to learn one of them well and only recur to the others when 
this one does not succeed. 

Von Troeltsch used mostly Kramer's method which we also adopted 
in our clinic. The lower nasal meatus is used as a passage. The distance 
from the point of the nose to the opening of the tube is not the same in all 
individuals and can therefore not be measured with the catheter. It va- 
ries within several centimeters according to the age and the different 
forms of the skull, viz. dolicho and brachycephalic, ortho and prognatic. 
We must therefore find another measure. It is found in the distance be- 
tween the opening of the tube and the rear wall of the naso-pharynx. The 
average is 15 millimeters (maximum 18, minimum 12 millimeters.) 

Here is in short Kramer's method. We push the catheter as far as 
the rear wall of the naso-pharynx. Then we draw it back 15 millimeters 
and turn it outward. 

There are a number of details to be watched. 

On the floor at the entrance there is a ridge across the nose which 
is covered with cutis. The mucous membrane starts on the inner side of 
it. The catheter has to be lowered so that its beak is horizontal in order 
to pass this ridge. 

The thumb and the two first fingers grasp the rear third of the 
catheter perpendicular to its axis (not slanting like a pen.) Then the 
arm is raised to a right angle. 

The catheter, when its beak has passed the ridge, must be perpen- 
dicular to the plane of the face. ,The beak touches the floor lightly and 
continues to do so while the catheter is pushed forward. It leans against 
the septum until it reaches the naso-pharynx. Deformities of the septum 
often cause an obstruction behind the entrance of the nose. It is some- 
times so close to the floor that the catheter cannot be advanced with its 
beak turned down. A beginner ought always to examine the nose with 
a nose speculum and a reflector in order to determine the cause and the 
shape of the obstruction. In passing around it not the slightest force or 
pressure ought to be used. It is better to try to find the course of the 
lower duct by making large curves outward or inward and upward with 



The Technic of Inserting a Catheter. 27 

the outer end of the catheter. We should always remember that the 
catheter which touches with the end and the convexity of the beak at the 
same time acts as a lever, the short end of which is in the nose, while 
we have the long end in our fingers. The pivot is the curve of the beak. 
We have to make large curves with the hand to bring about small mo- 
tions with the short beak. A slight pressure with the hand is multiplied 
at the end of the beak according to the distance of the end of the beak and 
the hand from the pivot. The beak usually enters without any difficulty 
if we make those curves towards one or the other side and upward. Care 
has to be taken that we do not lose touch with the floor and the septum. 
As soon as the beak has passed the limit between the hard and soft palate 
it can be easily turned to either side, at least in the cadaver. Frequent 
reflex motions are caused in the living. The soft palate rises like a cupola, 
the cartilages of the tubes protrude from both sides and the catheter may 
be immovably caught if the patient keeps on swallowing. To relieve the 
condition you ask the patient to breath quietly through his nose and 
close his mouth. You use the moment between two motions to give the 
beak its original direction downward, its position being indicated by a 
ring on the outside of the catheter, then bring back the rest of the cath- 
eter perpendicular to the plane of the face. 

We now take a firm hold of the bony part of the nose with the two 
last fingers. The weight of the hand rests on the patient's head which has 
to follow all movements. The catheter can usually, without any further 
interference, in the position we give it, be pushed ahead till it touches the 
rear wall of the naso-pharynx. It must not be left there long because this 
sensation causes the patient to gag. The two most disagreeable mo- 
ments of the whole procedure are, first the passage of the entrance of the 
nose, where the mucous membrane begins, and second a prolonged touch- 
ing of the rear wall of the naso-pharynx. In either of these two mo- 
ments we have to keep an eye on our patient, because he may suddenly 
raise his hands and pull out the instrument. We draw the catheter 
back 12 to 18 millimeters as soon as it has touched the rear wall. It has 
to maintain the same relative direction of beak and shaft. How far we 
have to draw it back depends upon the size and form of the head of the 
patient. Xow we rotate the catheter between our fingers outward and 
upward till the beak points upward and outward at an angle of 45 °, that 
is, in the direction of the outer angle of the eye. We feel the beak catch- 
ing in the tube, when we slightly push the outer end of the catheter 
against the septum. We recognize this when we can not rotate the 
catheter any further upward, nor push it any further inward, and because 
it does not move in swallowing; our hand and arm must rest steadily on 
the ridge of the nose of the patient while the catheter touches the rear 
wall of the naso-pharynx or remains in the tube. The patient must of 
course be cautioned against moving backwards. 

We recognize the correct position of the catheter also by the air 



28 The Technic of Inserting a Catheter. 

douche. We connect the catheterized ear of the patient with ours by 
a rubber tube (called auscultation tube, otoscope). Under normal condi- 
tions we hear the compressed air strike against the drum membrane with 
a continuous noise similar to that caused by rain falling on leaves in the 
woods. The air enters much more easily when the patient swallows dur- 
ing inflation. 

The most frequent mistakes are, firstly, that the beak at the beginning 
of the nose, enters the middle meatus which is more sensitive than the 
lower one. Secondly, that the catheter in the naso-pharynx deviates up- 
wards from its direction of a right angle with the plane of the face when 
its beak touches the roof of the naso-pharynx. Thirdly, that the catheter 
is not drawn back far enough and is rotated too soon. The beak then, 
instead of entering into the tube, enters into Rosenmuller's fossa where 
it may catch between folds and scars of the mucous membrane, giving the 
operator the sensation of having been caught in the tube. (Compare Fig. 
13). A noise is produced by inflation which may be heard at a consider- 
able distance similar to that of the wings of a flying bird. The beak of 
the catheter in this case has to be turned down and advanced again to the 
rear wall of the naso-pharynx to start anew. 

There are a number of other methods of inserting the catheter be- 
sides the regular one just described. You have to know them because 
you may succeed better sometimes by one, sometimes by another. 

Politzer in his text book advocates the so-called Kuh method which 
differs from Kramer's in that the beak of the catheter is turned outward 
till it touches the side wall as soon as it has touched the rear wall of 
the naso-pharynx. Continually touching the side wall it is drawn back 
and falls into Rosenmuller's fossa, then into the tube after having 
passed its ridge. I prefer the first method for the reason that the beak 
does not come in contact with so much ciliated epithelium. 

By the third method we do not start from the rear wall, but from the 
rear end of the nasal septum. The beak, when it has reached the soft 
palate, is turned in the opposite direction from the tube we want to cathe- 
terize, till it is horizontal. Pressing it slightly against the lateral wall of 
the nose the catheter is pulled back till the beak is caught at the rear mar- 
gin of the septum of the nose. The beak will now reach the tube if we 
turn it downward 180 plus one eighth of a turn upward and press the 
catheter against the septum. 

The fourth method may be used when the nasal passage is very oblique 
and when the beak of the catheter turns outward almost of its own accord. 
We may try in that case to insert the catheter directly into the tube. We 
can try the same method when the distance of the tube from the point of 
the nose is known from former treatments of this patient, who does not 
stand the touching of the rear wall of the pharynx very well. 

A fifth method may be tried when the lower meatus is obstructed. 
We insert the catheter through the middle meatus. When the beak 



The Tecknic of Inserting a Catheter. 29 

has arrived in the nasopharynx we often succeed in pushing the catheter 
down into the lower duct, whence we proceed as in Kramer's method. 

The sixth method tries to arrive at the point with the beak of the cath- 
eter turned upwards. This is indicated when the lower turbinal hangs 
very low and at the same time the septum is considerably deviated and 
thicker than normal. We start the insertion with the beak turned down- 
ward. We make a wide curve as soon as we meet an impassable obstruc- 
tion till the ring of the catheter points upward. The concavity of the beak 
in this position hugs the convexity of the lower turbinal. The catheter 
often passes easily a comparatively narrow and crooked canal. We ad- 
vance in this position to the naso-pharynx where we turn the beak down- 
ward. In order to succeed in this we must not turn towards the tube, but 
in the opposite direction. The beak being turned downward we advance to 
the rear wall of the naso-pharynx and proceed from there according to 
Kramer's method. 

The removal of the catheter which we have not yet mentioned re- 
quires special attention in the last named method. The rule is to remove 
the catheter in the same way it was inserted. Serious damage may be done 
if we do not follow this rule in the last method. The beak of the catheter 
can only be turned downward, not upward on account of the protrusion 
of the cartilage of the tube. The convexity of the beak will be caught 
against the convexity of the turbinal as soon as we try to extract the 
catheter in this position. The more we pull, the tighter it will be wedged 
in. A false passage will be bored in the mucous membrane of the floor 
of the nose with the point of the catheter, the moment we try to push the 
instrument back into the nasopharynx, if it has already arrived at the hard 
palate. The action of the lever that we spoke of before, helps to make 
matters worse. In order to disengage the instrument in this position 
probes have been inserted, or air inflated, which sufficiently^ explains the 
emphysema which was reported several times in the literature. It is 
therefore essential in this method that the convexity of the catheter be 
turned downward for the removal as well as for the insertion. 

Seventh Method : — We may reach the tube from the opposite nostril 
when the same side is absolutely closed to the catheter. Deviations of 
the septum are the most frequent causes for this. An abnormal width 
of the other side is a frequent consequence. A very strongly curved cath- 
eter may be introduced through that nostril to the rear wall of the naso- 
pharynx. It is rotated according to Kramer's method into the opposite 
tube. Auscultation will convince you whether or not the air enters into 
the middle ear. It is even frequently possible to catheterize both tubes 
if both ears are diseased, with the same strongly curved catheter, on 
account of the great width of the cavities of the nose. 

The eighth method deals with the introduction of the eustachian 
catheter through the mouth. This is impossible under normal conditions on 
account of the reflex movements of the palate. It would require another 



30 



Pointer's Method. 




rectangular curve of the catheter. The insertion through the mouth of 
our ordinary catheters offers no difficulties in congenital clefts of the hard 
and soft palate. The action of those muscles (described on page 22) 
which arise from the tubes and have their insertion in the soft palate is 
seriously interfered with in cleft palates. As a consequence the tubes and 
middle ear are very poorly ventilated. Repeated inflations of air at regu- 
lar intervals are necessary to avoid damage to the ear. The lower meatus 
generally takes part in the deformity. Therefore the only path for 
the catheter leads through the mouth. We can not see the opening of the 
tube, but we can find it from the rear wall of the naso-pharynx through 
the cleft. Sometimes the rear end of the lower turbinal is visible, which 
may be of help to us. The success of the air douche can often be heard, 
sometimes seen by the bulging drum-membrane, 
or proved by the considerable improvement of 
hearing. 

Either Politzer s single bulb or Lucae's dou- 
ble bulb may be used for inflation of compressed 
air. In double bulbs one acts as reservoir for the 
compressed air. Its advantages over the Politzer 
bulb is that the pressure can be regulated much 
better with the reservoir, than by compression of 
the bulb with the hand. The second point is more 
important. The double bulb emits a long lasting 
current of air, the entrance of which into the mid- 
dle ear can be heard much better with the ausculta- 
tion tube. Many a noise which may be caused by disturbance of 
secretion, etc., is lost to auscultation on account of its short duration 
in inflation with the Politzer bulb. 

The compressed air enters the middle ear more vigorously if the 
tube is opened by the act of swallowing while inflating. There is a clasp 
on the rubber tube from a compressed air reservoir which is given to the 
patient, so that he may open it himself the moment he swallows, in order 
to have the compressed air enter during swallowing. 

The air is compressed in some various clinics with other mechanical 
contrivances, instead of a bulb. (Lucae.) 

The introduction of inflation by Politzer 's method marked a great 
progress in otology. The insertion of the catheter in children can often 
be accomplished by force only. Politzer's method does away with the 
catheter. Every physician is able since then to treat successfully those 
extremely frequent diseases of the middle ears of children which are the 
origin of numerous persisting troubles. 

The double bulb is best used for Politzer's method. A short wide 
glass tube (compare fig. 15) is attached to the rubber tube of the reser- 
voir. The glass tube is inserted in one nostril, the rest of which as well 
as* the other nostril, are hermetically closed over it with the thumb and in- 



Fig. 15. 

Y natural size. 



Valsalva's Experiment. 31 



dex finger of the operator. The fingers of the other hand close the rubber 
tube below the glass tube. We let the air enter into the nose the moment 
that the soft palate closes the nose and nasopharynx in swallowing or 
crying. Little children can not be induced to swallow. They are laid on 
their back, their nose is closed with the glass tube in it. An assistant 
is ready to pour half a teaspoonful of water into their mouth when the 
tube is simultaneously opened. This is often the only way to force air 
into the middle ear of children only a few years old, or to recognize a 
small hole in the drum membrane from the noise of perforation, or to 
throw some secretions from the middle ear into the external meatus. 
Politzer's method often succeeds during crying also. 

This procedure can of course never fully take the place of the air- 
douche through the catheter. The current of air cannot be confined to 
one ear exclusively and its force cannot be controlled as safely. Valve-like 
occlusions of the tube are furthermore not infrequent occurrences. They 
may be absolutely impassable for Politzer's method, while the beak of 
the catheter easily enters them. Finally the noises which we hear through 
the auscultation tube are more unreliable in Politzer's method than those 
which are caused by the long lasting current of air through the catheter. 

Finally to force air into the middle ear there is the experiment known 
as Valsalva's test, because it was he who made it known. It consists of 
a forced expiration while the nose and the mouth are closed. It is used 
only in suppurations of the middle ear to force secretions through a per- 
foration in the drum-membrane into the external meatus. 



LECTURE V. 
Examination of the Middle Ear by Operation. 

Gentlemen : — Another avenue for reaching the middle ear is by open- 
ing the antrum and cells by means of an operation. 

For the present we shall see only in a general way at which places 
it is easiest to reach the antrum and cells by operation, i. e., where they 
are nearest to the surface of the bone. 

The mastoid parts of the temporal bones are so different one from the 
other, that it is difficult to find a fixed point from which to take one's 
bearings. As such I chose a little bony ridge on the rear and upper limit 
of the entrance to the meatus. It is found there pretty regularly and is also 
mentioned by Henle. I used it therefore for taking measures on the 
cadaver as well as for operation on the living. 1 I called it spina supra 
meatum. (Schwalbe later on tuberculum supra meatum.) The floor of the 
antrum mastoideum lies in a horizontal plane through the spina. 

The topography of the antrum and of the soft tissues of the outside 
of the skull can be studied very well in a horizontal section with the 
soft tissue still in place (comp. fig. 16). You see on such a specimen 
that the concha is not fastened to the side wall of the skull directly behind 
the meatus, but that there is a thick layer of tissue between the cartilage 
and the periosteum of the pars mastoidea. The fold which the skin makes 
in reaching from the rear surface of the concha to the side wall of the 
skull, is on an average, 15 millimeters behind the auditory canal. The rear 
end of the antrum as you see does not reach as far back as this fold. This 
fold is on the contrary opposite the sigmoid sinus which is often very close 
to the outer surface of the bone. It is therefore of no advantage to cut 
the skin as is often recommended in a curve behind the insertion of the 
concha, but, if we want to reach the antrum by the shortest road, we must 
cut in a straight tangent through this line. We are opposite the antrum, 
if we push the soft parts and the periosteum forward. The antrum is 
found at an average depth of 12 millimeters if we open up in a transverse 



*) The perforation of the mastoid process from an anatomical standpoint. Monatsschrift f. O. 
1873 No. 11 to 1874 No. 2. 

32 



The Examination of the M. E. by Operation. 



33 



direction inward directly behind the spina supra meatum, which should be 
located in every case. 

The acute suppurations of the middle ear which call for these opera- 
tions have their focus often not exclusively, in many cases not at all in the 
antrum, but in some of the cells of the periphery, the large terminal cells. 
The operation therefore cannot be confined to the opening of the antrum, 
but must be extended to the cells. Therefore the whole external wall of 
the mastoid process must be removed. We generally find one or several 
cells in the tip of the mastoid filled with pus. A cavity with smooth 
walls all around, which is open wide towards the outside has to be formed 




Horizontal section through the temporal bone in the level of the spina supra 
meatum. The soft tissues are left intact. 

a external meatus, b drum-cavity containing the hammer and anvil, c antrum mastoideum, d 
pneumatic cells surrounding the labyrinth, e sinus sigmoideus, / posterior limit of the insertion of 
the auricle, g cut through the mastoideo-squamous fissure. 



out of all the cells. Sometimes on account of local inflammations we are 
obliged to open cells which are not in the mastoid process but in its sur- 
roundings. 

A large cell filled with pus is especially often found on the floor of 
the temporal bone inside the incisura mastoidea. This cell can be suffi- 
ciently exposed in some cases only, by removing the inner surface of the 
mastoid process and the bony floor of the suppurating cavity. In this 
connection we must not forget that often this medial wall which is covered 
with pus and granulations may be the wall of the sigmoid sinus, which 
also may be wanting. Usually a swelling of the neck below and around 
the mastoid process points to the deep-seated suppuration. In other cases 
the appearance of a drop of pus in one of the uncovered cells points to 
one of those deep-seated pus cavities. 

Cells filled with pus are found in rare cases behind the mastoid pro- 
cess and at the root of the zygomatic process. Both of those places are 



34 The Examination Through the External Meatus. 

usually betrayed by the swelling and sensitiveness to pressure of the soft 
parts covering them. 

The rear end of the antrum in very small children is only very slightly 
below the outer plate of the bone. The mastoideo-squamous fissure runs 
over it in a vertical direction. In order to lay bare the field of operation 
the concha together with the periosteum must be loosened from the bone 
up to the meatus in very small children as in adults. Neither the spina 
supra meatum nor the crista temporalis is clearly visible in very small 
children, which makes the topography of the outer surface of the mastoid 
process at that age very difficult. There are no cells except the antrum 
which in the new-born is of the same size as in the adult. 

It is not sufficient in chronic suppurations of the middle ear which 
must be operated upon, to open up the spaces temporarily ; we have to 
make a radical operation which keeps them open perpetually, in order to 
control them forever after. For that purpose we remove the outer wall 
of the antrum, together with the outer wall of the aditus which is the 
rear and upper wall of the external canal. The peripheral cells in such 
cases are usually completely obliterated on account of the preceding years 
of inflammation. 



Examination through the External Meatus. 

The third avenue of access to the ear leads through the external 
meatus, of which we now wish to study the form and topography. 

The ear surgeon must know the form and the position of the meatus 
very accurately. The most important of our diagnostical examinations, 
the inspection of the drum membrane is accomplished through it, as also 
a number of operations on the drum membrane and in the drum cavity. 
Changes of its form like swelling or sagging of the posterior upper wall, 
fistulas, etc., may give us important information as to diseases of the 
spaces of the middle ear around it. Finally an accurate knowledge of its 
form is an absolute necessity for every one who wants to use instruments 
to remove foreign bodies which so frequently get into the meatus. Blind 
zeal and lack of knowledge in this respect have destroyed the hearing and 
even the life of a number of children. 

Whoever wants to operate in a meatus which is occluded by some 
foreign body or new formation (exostosis, etc.) must know its form so 
vvell that he can reproduce it before his mind's eye at any time. This 
ability can not be acquired in dissecting nor in studying series of cuts in 
different directions. There is only one means of seeing the form of a 
complicated cavity as a whole and preserve it in our memory, namely by 
making a number of casts of it. 

The meatus commences from the rear surface of the tragus, where 
the cartilage of the concha turns inward and becomes tube shaped. The en- 



The Examination Through the External Meatus. 35 

trance of the meatus is an oblique plane just as its other end, the drum 
membrane ; oblique though in opposite directions. 

The cartilaginous part is not quite one third of the whole meatus. 
The cartilage does not form a tube, it forms only a groove open at the top. 
The gap is filled by membranous parts. It has two fissures which are 
perpendicular to its axis in the lower anterior wall called incisurae San- 
torini. They are of practical importance because abscesses in the neigh- 
borhood, for example in the parotid gland may perforate through them 
into the meatus, or furuncles of the meatus, may enter the surrounding 
soft tissues by gravity. The anterior lower and some of the rear part 
of the bony meatus of the adult is formed by the groove shaped os tym- 
panicum. The rear upper and uppermost part belong to the squamous 
portion. There is some fibrous tissue between the cartilage and the outer 
rim of the os tympanicum which permits straightening of the curved 
canal by drawing the auricle backward and upward. Abscesses of the 
neighborhood may perforate here also. The perforations are often ar- 
ranged in the shape of a rosary. 

The aperture of the meatus is oval. It runs horizontally inward and 
a little forward. There are however two deviations from this direction. 

The first is a zigzag bend, the second a spiral shaped twist of the 
axis. 

The first bend is between the wall of the tragus and the cartilagi- 
nous meatus, where we also find the external incisura Santorini. The 
wall of the tragus runs forward and inward, the meatus backward and 
somewhat upward. The second bend has an opposite direction. It is 
between the cartilaginous and the bony meatus which runs in a slight 
curve inward, somewhat forward and downward. 

The spiral shows the best in a series of cuts from the outside inward 
which are perpendicular to the axis. 

The aperture at the entrance changes its form and size (compare 
fig. 21, I. page 37) according to the position of the lower jaw, whether 
the mouth is open or closed. A cross cut here is nearly oval. The longer 
axis is vertical. It may become so narrow in old people, that it forms 
simply a vertical slit, especially in women with flabby skin, (compare fig. 
22). 

The floor of the cartilaginous meatus rises towards its inner end, 
which accounts for the fact that this part becomes narrower. A form 
like an isthmus results where it joins the bony canal, which however 
varies greatly in different individuals (compare fig. 21 II). 

The cross cut of the bony canal has somewhat the shape of a tunnel. 
The anterior and the lower wall which are formed by the os tympanicum 
are nearly straight (compare fig. 21, III). The rear and upper part of 
the wall which belongs to the squamous portion forms a highly curved 
arch over it. The bony canal persists in its shape of a tunnel throughout 



36 



The Shape of the External Meatus. 



its length and runs in a slight curve inward and somewhat downward and 
forward. 

The beginning of the bony canal is considerably wider than the 
isthmus at the end of the cartilaginous canal (compare fig. 21 II. and 
III.). It becomes narrower again towards the inner end, where it is 





Fig. 17. 



Fig. 18. 





Fig. 19. Fig. 20. 

Figs. 17-20. 

Cast of the external canal. In Fig. 17 as seen from in front, in Fig. 18 from 
the rear, in Fig. 19 from above, in Fig. 20 from below. 

more the horizontal diameter which shrinks, so that the tunnel becomes 
flatter (compare fig. 21 III. and IV.). 

Comparing the cuts through the aperture in fig. 21 I. to IV. you will 
notice that the upper end of the long diameter turns more and more for- 
ward so that at the end of the canal (cut IV.) it has an angle of only 45 
degrees with the horizon, while in the beginning it was 90 degrees. 
The spiral twist of the axis is thereby proven. 

You will understand now why neither horizontal nor sagittal cuts 
through the skull can give an accurate impression of the form of the 
meatus. The inner end in a horizontal cut seems enlarged on account of 



The Shape of the External Meatus. 



37 



the spiral twist. Much less can vertical cuts give a clear picture, since 
the spiral twist as well as the zigzag shape are lost to view. 

The arabic numbers in fig. 21 give the average length of the longer 




I. 



E 



6.0 



6.1 



4:6 



SJ 



r 



78 8.7 

Fig. 21. 

Section through the meatus perpendicular to its axis. 

/ at the entrance, 77 at the end of the cartilaginous part, III at the beginning of the bony part. 
/y at the end of the bony part. 

and shorter diameter of the different cuts through the meatus. I obtained 
those numbers by measuring a great many corrosion casts of the canal. 
The most important cut is the innermost. Its 
longer diameter is 8.1, its shorter 4.6 millimeters. 
It forms the door for examinations of the drum 
membrane with the ear speculum as well as for 
the introduction of the instruments in the opera- 
tions on the drum membrane and drum cavity. 
It is a matter of every day experience that a mod- 
erate swelling of the walls in this place can con- 
vert the narrow oval into a slit which hides the 
drum membrane from our view. 

The length of the canal from the point of the 
tragus to the anterior and lower end of the drum 
membrane is 35.2 millimeters. Its length from 
the rear part of the rim of the entrance is accord- 
ing to v. Troeltsch 24 millimeters, with which my 
measurements nearly coincide. 

It simplifies matters to speak of two walls of 
the canal only instead of four on account of its 
partly oval, partly tunnel-like shape. The ante- 
rior wall in the depth becomes the anterior and 

lower wall. The posterior wall in the deeper parts becomes the rear 
and upper wall which there forms the highly curved arch over the 
anterior wall. 

We have to consider the innermost part of the meatus, which is 
medial from cut IV. The lower anterior wall is the continuation of the 
anterior wall with its slight spiral twist. In place of the upper and poste- 
rior wall there is the drum membrane which cuts through the canal in a 
very oblique direction (compare fig. iy to 21). 




Fig. 22. 

Cast of the meatus 

of an old woman, 

as seen from 

above. 



38 The External Meatus of the New-born. 

The plane of the drum membrane is very oblique as compared to 
the sagittal plane of the skull. Its upper and rear margin is much more 
lateral than its lower and anterior edge. Supposing the membranes of 
both ears be sufficiently enlarged, they would meet in a line in front of the 
head, which runs in the median plane slanting from forward and upward 
to downward and backward. 

The form of the drum membrane depends upon the oblique direction 
in which its plane cuts the meatus. If it were perpendicular to the axis, 
it would have the form of cut IV (fig. 21). It is oval however or has 
somewhat the shape of a heart in playing cards as a consequence of its 
oblique position. The largest diameter runs from the rear and upward 
to the front and downward. It is on an average of 9.2 millimeters long 
according to the measures taken on casts. The shorter diameter runs 
from the rear part of the base to the front of the top and measures 8.5 
millimeters. 

The rear upper zvall of the meatus passes in a slight curve into the 
drum membrane, so that there is no angle of 140 or less, as some text 
books give it. The limit between the rear wall of the meatus and the 
drum membrane can under normal conditions only be recognized from the 
difference in color of both. It is very liable to disappear when there is 
injection of blood vessels or infiltration. These points are often very 
important. 

The angle of the lower and anterior wall and the drum membrane 
according to the casts is much more acute than it appears from our inspec- 
tion or from former authors. This angle in casts is from 23 to 31.5°; 
on an average 2j l / 2 ° . The drum membrane changes its position very 
little as we shall see in the description of the triangular reflex. The dif- 
ferent size of that angle depends therefore in the first place upon the 
smaller or larger curve of the canal and the protrusion of its lower and 
anterior wall. 

The rccessus meatus is the space in the acute angle between the 
drum membrane and the lower anterior wall of the canal. This space 
may be hidden from our view through the speculum when the anterior and 
lower walls protrude considerably. Perforations of the drum membrane 
and foreign bodies may remain there undetected by our eye. In rare cases 
this protrusion may cover more than the anterior lower half of the drum 
membrane. Usually however we are able to see this space as well as the 
remainder of the canal and drum head (compare sulcus reflex page 46). 
The meatus of the new-born and of children of a few years is quite differ- 
ent. They have no bony canal at all. The os tympanicum is not a tube, it 
is merely a ring, called the annulus tympanicus in which the drum mem- 
brane is inserted. The tube shape is developed later on when the horizon- 
tal part of the squama is formed and the annulus tympanicus becomes a 
bony groove. An irregular round defect of ossification which is closed by 
connective tissue only, often remains in the anterior lower wall up to the 



The She of the Meatus. 39 

fourth year and exceptionally even in the adult. The external meatus of 
the new-born, the walls of which are membranous throughout, leave only 
a little horizontal slit between themselves and the drum membrane. This 
slit is filled after birth with vernix caseosa. The membrane can be seen 
only very incompletely in the first few months of life even if all the vernix 
is removed. 

The meatus of an adult contains about one cubic centimeter accord- 
ing to Hummel. We measure it by filling it with water. This method 
of measuring may become of practical importance in those compar- 
atively frequent cases where large pathological cavities communicate 
freely with the meatus. 

We will now proceed to describe the surroundings of the meatus. 
The parotid gland encloses the cartilaginous meatus downward and for- 
ward. The glenoid process of the lower jaw lies close to the upper part of 
the anterior wall. In opening the mouth the entrance of the meatus be- 
comes wider. Pains in the joint of the jaw are often described as ear-ache 
by the patient. Pressure in front of the tragus while the patient opens 
his mouth gives us information about the real seat of the pain. Crepitus 
sometimes can be felt in the joint. Large cells of the mastoid process 
often lie close to the rear wall of the bony canal. Fistulas may lead into 
the canal- through this wall. The mastoid antrum, the aperture of which 
is often not more than five millimeters from the aperture of the canal, 
is medial from these cells. It runs in a slight curve over and behind 
the rear wall (compare fig. 5 page 9). Destruction of the rear 
wall of the bony canal leads frequently to communications between the 
meatus and the cells of the mastoid process. Small pneumatic cells are 
sometimes found in the roof of the meatus. They not infrequently com- 
municate with the large cells at the base of the zygomatic process. 



LECTURE VI. 

The Picture of the Tympanic Membrane on Examination 
with the Ear Speculum. 

The rapid progress of otology in diagnosis and therapy became pos- 
sible only after v. Troeltsch taught us to throw light with a perfo- 
rated reflector on the drum membrane when it became visible to the eye 
of the observer. 

For illumination of the meatus and the drum membrane we use 
wherever it is possible diffuse day light in a room with one window only. 
The distance from the window is irrelevant. A concave mirror is used, 
the diameter of which is 10 centimeters, its focal distance 15 centimeters. 
It has to be held at a distance of 12 centimeters from the entrance of the 
meatus in order to have the focus on the drum membrane because of the 
length of the meatus. 

Anomalies of refraction or accommodation in the examiner must be 
corrected with glasses. 

We use a forehead mirror of a larger focal distance (18 centimeters) 
for operating in the canal, in order to leave space for the hand to act. 

Nernst lamps and Welsbach lights are preferable for artificial illum- 
ination. Their light is concentrated by means of lenses or the so-called 
"Schusterkugel" which was introduced by Oertel into laryngology. The 
advantage is the large area of light for the examination. A kerosene 
lamp however may give sufficient light to see the drum membrane. 

Politzcr's hard rubber ear specula are used to straighten and enlarge 
the cartilaginous meatus. Their aperture is round and of three different 
sizes. The ear speculum must not be inserted deeper than the cartilagi- 
nous meatus. The canal is straightened by pressing the rear wall of the 
speculum against the rear wall of the meatus and simultaneously 
pushing or pulling back the auricle with the middle finger which is 
inserted into it. The use of the speculum as well as the insertion of 
the catheter have to be learned in special courses. 

Light has to be thrown into the meatus before inserting the speculum 
in order to recognize fistulas and other changes around the entrance. 

40 



The Tympanic Membrane. 41 

Looking through the speculum one must not forget that the walls of 
the meatus and the larger part of the drum membrane can be seen fore- 
shortened and with one eye only. An accurate estimate of the depth is 
therefore very difficult. It can be learned only by constant practice in ex- 
amining a large number of normal ears. 

The condition of the drum membrane, as we see it through the 
speculum gives us information concerning pathological changes which are 
located in it. Even though it may not be diseased itself, its partial trans- 
parency and easy changeableness of form put us in a position to draw 
conclusions as to diseases which are located in the drum cavity or in dis- 
tant parts of the middle ear. 

First you ought to know accurately how a normal drum membrane 
looks. It is however at least as important to know from your own exper- 
ience the many variations which may be present without interfering with 
hearing and which therefore must be considered as relatively normal. 
From my own experience I cannot recommend to you a better field of 
practice than to offer your services for the examination of school children. 
The interest which at present the work of physicians in the schools has 
aroused will afford you ample opportunities for such study. 

The drum membrane consists, as you know, of three layers, the 
cutis of the external meatus, the membrana propria, and the mucous mem- 
brane. The membrana propria has two layers an outer in which the fibres 
are arranged radially, and an inner one with circular arrangement. The 
rim of the drum membrane is thickened and is called the limbus tendino- 
sus. The limbus tendinosus is inserted into the sulcus of the os tympani- 
cum like the crystal of a watch is inserted into the rim. The sulcus goes 
only as far as the os tympani reaches. We have heard that this is want- 
ing at the top and that the horizontal part of the squama fills the gap. 
There the membrane is attached directly on to a sharp rim of the squama 
and forms the incisura Rivini, which is a small notch either round or scal- 
loped. The meatus and the aditus ad antrum meet in this sharp rim at 
an acute angle. 

The part of the drum membrane which covers the notch has no 
membrana propria like the rest. It is therefore thinner and flabby. We 
call it the pars flaccida Shrapnelli, while the rest of the membrane is called 
the pars tensa. The line which marks their division is the thickened upper 
end of the membrana propria, which can be recognized from the outside 
as two short cords. The anterior one is usually more pronounced than 
the posterior one. They are called the two liminal strands. They start 
from the anterior and posterior corner of the incisura Rivini and run 
downward towards each other in a very obtuse angle. They meet in the 
little protuberance which the short process of the malleus forms in the 
drum membrane. 

Prussak's space is a small flat pouch on the inside of Shrapnell's 
membrane, between this membrane and the neck of the hammer which 



42 _ The Tympanic Membrane. 

runs upwards from the short process. Its upper limit is the transverse 
ligament of the hammer, its anterior limit is the anterior liminal strand of 
the drum membrane. It opens in the rear towards the aditus ad antrum. 

The protuberance of the short process is the best point from which to 
take our bearings for the surface of the drum membrane. It usually 
shows as a yellow spot even when the cutis is much swollen and injected. 
The short process and the neck of the hammer are often intact when the 
drum membrane is destroyed very extensively. 

The outer edge of the handle of the hammer is usually visible as a 
whitish, straight or slightly curved line running from the short process 
downward and slightly backward to a little below the center of the mem- 
brane. Sometimes it looks only like a small crest which forms the limit 
between the anterior and posterior half of the membrane. 

You divide the drum membrane in four quadrants, by prolonging the 
line of the handle of the hammer to the lower and posterior rim, and 
drawing a perpendicular line to this through the end of the handle. This 
division is generally accepted and practical. The quadrants are not 
equally large, the two rear ones are larger than the front ones and the 
upper ones larger than the lower ones. 

The color of the drum-membrane is influenced by its transparency. 
It is pearly gray although it is covered with white epidermis. Towards 
the center it has a yellowish tint from the bone of the promontory which 
lies close behind it. 

The thinnest part of the drum membrane, the intermediary zone, ap- 
pears diffusely pinkish, whenever the blood vessels of the inner wall are 
injected. On the other hand, an injection of the blood vessels of its cutis 
shows mainly along the handle of the hammer, where the main blood ves- 
sels of the cutis run, and all along the periphery, where a great number of 
radial blood vessels pass over from the meatus to the drum membrane. 

The thicker and therefore opaque parts of the membrane are more 
whitish (compare table of drum membranes, fig. I). As landmarks 
of the membrane we recognized the anterior and posterior liminal strands, 
the short process, and the handle of the hammer. Frequently there is a 
lighter spot at the lower end of the handle of the hammer called the umbo 
of the drum membrane. It is produced partly by a spatula-like enlarge- 
ment of the lower end of the handle of the hammer, partly by a closer 
arrangement of the radial fibres of the drum membrane. The limbus of 
the drum membrane appears often as a narrow white zone which is 
sharply circumscribed in its outermost periphery. The cutis of the rear 
and upper part of the bony meatus contains the blood vessels and 
nerves of the drum membrane enclosed in a layer of subcutaneous cellular 
tissue. The rest of the bony meatus however is lined with thin cutis 
which is closely connected with the periosteum. The thicker layer of 
connective tissue passes together with the blood vessels and nerves over to 
the drum membrane, and there forms a light stripe in the rear and upper 



The Tympanic Membrane. 43 

quadrant, which runs parallel to the handle of the hammer. It is wide 
on top, but becomes narrower further down, it terminates in a sharp 
line at the end of the handle. 

The contours of parts in a drum cavity are recognizable through the 
drum membrane as lighter lines. The posterior fold of the drum mem- 
brane which forms v. Trocltsch's rear pouch may appear in the rear 
upper periphery as a downward concave line which ends at the handle 
of the hammer. The rear part of this contour may be formed by the 
chorda tympani, which runs along the posterior fold of the drum mem- 
brane, and, after having passed the handle of the hammer, runs into Glas- 
er's fissure. A shorter light streak may appear belozv this contour, when 
the drum membrane is very transparent. It is nearly parallel with the 
handle of the hammer. There is frequently another light streak running 
backwards from its end towards the periphery at right angles to the first 
one. The vertical streak is the lower end of the long process of the incus. 
The horizontal one is the tendon of the stapedius muscle, and is not the 
rear horn of the stirrup, as was generally believed according to Politzer. 
This is shown firstly by the fact that this streak is always straight, and 
secondly, one can see it with one's own eye whenever there is a large 
defect in the rear upper quadrant of the drum membrane. The entrance 
to the niche of the round window can be seen sometimes as a dark spot in 
the rear lower quadrant. The upper anterior quadrant appears darker 
than the rest of the drum membrane on account of its deeper position and 
the shadows which are thrown upon it. 

The picture of the drum membrane is very much influenced by its 
different curves. We did not enter into a description of details in order 
not to complicate matters. 

The drum membrane as such is funnel shaped. The opening of the 
funnel is directed towards the meatus. The periphery forms a plane 
through the sulcus tympanicus around the rim of the funnel. Every 
radius of the funnel is slightly convex towards the meatus. 

There are no folds in the drum membrane under normal conditions 
except the two liminal strands. The development of folds which were de- 
scribed in the normal drum membrane has to be attributed to past or 
still existing pathological processes. It is important to state this fact since 
it influences our judgment of the findings of the drum membrane. We 
can therefore infer from a typically normal drum membrane, which has 
no folds whatsoever, that there were never any pathological processes, 
especially of the tubes, which always leave persisting changes of the drum 
membrane whenever they have lasted for some time. 

The form of the drum membrane changes as soon as the equilibrium 
of the air pressure on the outside and on the inside of it is disturbed. 

Whenever the air in the spaces of the middle ear is rarefied, which 
many people can accomplish by swallowing while their nose and mouth 
are closed, the convexity of the radial fibres of the drum membrane disap- 



44 



The Tympanic Membrane. 



pears and the exact form of a funnel becomes more or less pronounced. 
(Compare Fig. 23c.) 

Whenever the air in the middle ear is compressed as for example in 
Valsalva's experiment, the drum membrane bulges visibly, and the convex- 
ity of the fibres of the funnel outward increases considerably. (Compare 
Fig. 23 b.) 

All these changes of form of the drum membrane are clearly recog- 
nized in examinations of the drum membrane through the ear speculum, 
from the alteration in the form of the light reflexes which occur on the 
surface of the drum membrane. Their description will be considered in 
the next chapter. 

The so-called normal reflex of the drum-membrane (compare Fig. 
23a and 24) has the form of a triangle, the apex of which is in the 




Section through the tympanic membrane in the axis of the meatus through the 
middle of the triangular reflex. 

a normal curve, 6 bulging, c funnel shaped slight retraction, d pan shaped (moderate) retraction, 
e kettle shaped (highest degree of) retraction. 



umbo, the base is directed towards the anterior and lower part of the 
periphery. The base does not quite reach the periphery and is indistinct. 
The funnel shape of the drum membrane is the cause of the triangular 
form of the reflex. The constant location of the reflex in the anterior 
lower quadrant is explained by the doubly oblique position of the drum 
membrane The illumination of the surface of the drum membrane is ef- 
fected by the reflector, the axis of which is also our axis of vision. A re- 
flex can only be seen on such parts of the drum membrane as throw back 
the light in exactly the same direction as that in which it came. The ra- 
dius of the wall of the funnel which is perpendicular to our axis of vision, 
and its immediate surroundings fulfill that condition. The direction of our 
axis of vision with the drum membrane being determined by the axis of the 
meatus, and the position of the membrane being determined by the same 
axis, it is easily recognized from Fig. 23, that the triangular reflex can 



The Tympanic Membrane. 



45 



only occur in the lower anterior quadrant. Supposing the funnel shaped 
surface of the drum membrane were directed downward, the triangular 
reflex would run vertically downward from the umbo. The reflex would 
be seen horizontally forward, if the funnel shaped surface were directed 
forward. It is evident that the direction of the light reflex must be be- 
tween the two directions, since the obliquity of the drum membrane is 
between the two just named directions. We are even able to infer the de- 
gree of obliquity in one or the other direction from the more vertical or 
more horizontal position of the reflex, provided the funnel be regularly 

shaped. We learned that the fun- 
nel does not reach the periphery of 
the membrane, therefore the light 
reflex can not do so either. 

A triangular reflex would be 
impossible if the drum membrane 
were so oblique that no radius of 
the funnel were perpendicular to 
the axis of vision. The normal re- 
flex was absent in 4.1 per cent of 
614 ears which I examined in 
school children. I became con- 
vinced at that time that it does not 
influence the function of the ear 
whether it be triangular, distinct 
or indistinct, whether it be inter- 
rupted in its length or in its width, 
or whether it be reduced to a sim- 
There is one condition absolutely 
necessary in order to give the reflex the predicate normal, that 
is, it must reach to the umbo, or very nearly so with its point, 
be it ever so indistinct. This is possible only under the condition that the 
drum membrane has preserved its shape of a funnel. It is immaterial if 
the point of the funnel be dull, since this is occasioned by the enlargement 
of the end of the handle of the mallet. 

The great regularity of the normal reflex must be taken as a proof 
for the following facts : the relative position of the drum membrane and 
the axis of the meatus is the same in all people, because the lozver anterior 
quadrant of the membrane is always met in the direction of the axis of 
the meatus by the sound rays, that is in a perpendicular direction. 

The form of the normal reflex will change of course whenever the 
drum membrane is retracted or bulges. In the first case it becomes nar- 
rower and longer, because the membrane becomes more funnel shaped 
(compare Fig. 23c) ; in the second case it becomes wider, shorter and 
more indistinct (compare 23b). Its point however reaches the 
umbo as long as the drum membrane keeps the shape of a funnel. 




Schematic demonstration of the 
normal reflexes of the tympanic 
membrane. 

pie indistinct spot in the umbo. 



46 The Tympanic Membrane. 

Another small reflex of light is found sometimes on the short process 
of a normal drum membrane. It is a reflex from the convexity of the ball 
shaped cartilaginous covering of the process. 

Two more reflexes as from a hollow ball are found on the drum 
membrane. The first one is found at the anterior limit of Sharpnell's 
membrane. It is not always seen on the normal membrane ; whenever it 
expands over a large part of the surface of the Sharpnell's membrane it is 
pathological. The other reflex is seen constantly at the lower and anterior 
periphery of the drum membrane. It is a narrow streak of light like a line 
of light of several millimeters, which is not located on the membrane itself, 
but is formed in the groove between the external part of the sulcus pro 
tympano and the wall of the meatus. I called it therefore the "sulcus re- 
flex." It can be seen only when the recessus of the meatus is not con- 
cealed by the protruding anterior and lower wall of the external canal. 
Whenever we are able to see it, we know that we can see the whole drum 
membrane. In many cases it can be made visible only by a forcible 
straightening of the meatus. The beginner in examination has an assur- 
ance of focusing correctly when the sulcus reflex appears. I found it 
covered by the wall of the meatus in 30.6 per cent of the ears which I ex- 
amined in pupils of the public schools. This shows that zve are able to 
see the whole drum membrane in at least two-thirds of all children, if the 
meatus is otherwise normal. 

Another crescent-shaped reflex appears finally on the rear and upper 
periphery of the drum membrane whenever it bulges very much, either as 
a consequence of the air douche or Valsalva's experiment. Its lower limits 
are indistinct. It occurs because the rear and upper periphery becomes 
perpendicular to the axis of vision. (Compare Fig. 23b, and 24m). 

The position of the three reflexes just described, the triangular, the 
sulcus and the reflex of the bulging is characterized in that a line which 
cuts the triangular reflex lengthwise in two halves, also cuts the other re- 
flexes in two halves. (Fig. 24.) 

All other reflexes zvhich may become visible on the drum membrane, 
as also the removal of the triangular reflex from the umbo, are not nor- 
mal, but indicate pathological changes of the form of the drum membrane. 
This is one of the reasons for entering carefully into the description of 
the form and origin of the normal reflexes of the drum membrane. The 
origin of the different pathological reflexes will be studied in the special 
part. 



LECTURE VII. 
Physiological Preface. 

Gentlemen : — We should know at least the most important points of 
the complicated mechanical contrivances which help to produce the sensa- 
tion of hearing in order to understand the disturbances of the function of 
hearing. 

The external canal together with the auricle must be considered as 
a collecting pipe for the sound waves. It allows, whenever it is very 
wide, a part of the sound waves to pass without deflection, so that they 
strike the lower anterior quadrant of the drum-membrane perpendicularly. 
Another large part of the sound waves is reflected inwardly from the 
walls of the concha and meatus, so that they also reach the drum mem- 
brane more or less perpendicularly. 

Narrowness of the meatus, even if only a very small aperture is left 
has little influence on the acuteness of hearing. I became convinced how- 
ever that it is not entirely a matter of indifference for the perception of 
high sounds. 

The sound conducting apparatus consisting of drum membrane, os- 
sicles and ligamentum annulare forms a mechanism of wonderful preci- 
sion. 

Most of the simple words like numbers can be understood in a whis- 
per at a distance of 89 meters and more, in an absolutely quiet room, ac- 
cording to examinations which I induced Morsak to make. 

The mathematician Riemann found by calculation that the magni- 
tude of the movements which are exactly transmitted by the drum 
membrane to the foot plate of the stirrup of a person who hears at such 
normal distances, are fai below the limit of our microscopical observa- 
tion. Newer investigations showed that the movements of the foot plate 
of the stirrup must actually be much smaller than Riemann thought they 
were. 

Ed. Weber advances the theory that the whole sound conducting ap- 
paratus together with the column of water which runs up the scaia vesti- 
buli and back the scala tympani, moves backward and forward as a zvhole 

47 



48 The Function of the Sound Conducting Apparatus. 

with each sound wave. The very flexible and yielding membrane of the 
round window acts as a siding, v. Helmholts found the mathematical 
proofs for the accuracy and even necessity of this theory. 

v. Helmholts taught us furthermore that the drum membrane to- 
gether with the ossicles forms a wonderful lever apparatus, which is able 
to convert large movements of low power into small movements of high 
power at the foot plate of the stirrup which is suspended at the ligamen- 
tum annulare. 

This whole apparatus, according to Riemann, is so well balanced that 
the smallest amount of energy is sufficient to over-balance it. 

There are two pairs of antagonists acting on the drum membrane 
and the sound conducting apparatus, which explains how this requirement 
which is a priori necessary, is fulfilled. 

The first pair are the radial and circular fibres of the membrana pro- 
pria of the drum-membrane. The second pair are the two muscles in the 
drum cavity. 

The antagonism of the radial and circular fibres of the drum mem- 
brane is visible in the convex form of the funnel of the drum membrane. 
(v. Helmholts.) The tensor tympani muscle, by its elastic traction which 
lasts even while the muscle is at rest, stretches the axis ligament and the 
other ligaments which have their insertion on the neck of the hammer. 
Secondly it tries to straighten the radial fibres of the drum-membrane. 
This effect is not very strong because its insertion on the handle of the 
hammer is not favorable, it being far away from the most efficacious 
place, namely the lower end of the handle of the hammer. Nevertheless 
this effect from which the muscle has its name, can not be doubted. The 
radial fibres, if they existed alone in the drum-membrane would be drawn 
straight by the tendon of the tensor muscle, of which they are a contin- 
uation. Their form, which is convex towards the meatus, can only origin- 
ate from the circular fibres which are somewhat elastic on account of 
their length, run on the inside of the radial fibres and have their insertion 
on the handle of the hammer. Their bracing effect is the most pronounced 
in the intermediary zone of the funnel of the drum membrane. 

Each phase of the sound waves, positive as well as negative, strikes 
the whole surface of the drum membrane evenly, on account of their 
great length, at least as far as they belong to the musical part of the 
sound scale. They travel in the direction of the meatus. 

The circular fibres are always the first to be affected by the positive 
as well as by the negative pressure which acts on the drum membrane. 
The elasticity of the circular fibres is favored during rarefaction of the air 
in the meatus, i. e., the convexity of the funnel is increased. The positive 
pressure in the meatus on the other hand works against their action and 
supports the traction of the tendon of the tensor muscle, which tries to 
straighten the radial fibres, v. Helmholts found by calculation that fibres 



The Function of the Sound Conducting Apparatus. 49 

of so flat an expansion are moved very easily and very extensively by the 
weakest pressure, and that they communicate their very much smaller, 
though very much stronger motions to their point of insertion which, 
in our case, is the handle of the hammer. "It is very similar" he says "to 
the increase of power by means of a lever." 

. It is quite extraordinary that v. Helmholtz did not notice the antag- 
onism of the second pair of powers which act on the chain of ossicles. 
They are the two muscles in the drum cavity. He studied only the action 
of the tensor muscle and not that of the stapedius muscle. 

The great importance of this muscle for the fixation and motion 
of the sound conducting chain may be inferred from its mode of inser- 
tion which is nearly at a right angle. Hardly any other muscle in the 
whole body is situated so favorably. 

The fibres of its tendon, which comes from the rear and a little down- 




Fig. 25. 

Right foot plate of the stapes together with the ligamentum annulare, accord- 
ing to Eysell. 
as seen from within, b c axis ligament of the foot plate. 

ward and upward, are inserted, according to Rildingcr, partly on the head 
of the stirrup and partly on the rim of the joint of the processus lenticu- 
laris which belongs to the long process of the incus. 

Let us contemplate its effect on the stirrup alone. 

In an early paper by Eysell we find a very good description of the 
manner in which the foot plate of the stirrup is connected with the pelvis 
ovalis by means of the ligamentum annulare. 1 

The picture (fig. 25) which is taken from Eysell shows that the 
foot plate of the right stirrup as seen from the vestibulum resembles 
very closely the sole of the right foot. The rear part of the ligamentum 
annulare all around the heel is very narrow and thick. It becomes 
broader and thinner towards the front (compare fig. 26). It is widest in 
front and upward (a to d fig 25). A vertical part of the ligamentum 
annulare nearest the rear pole of the foot plate "acts as an axis ligament" 
during the traction of the tendon of the stapedius muscle. The rear 



*) "Beitrage zur Anatomie des Steigbugels und seiner Verbindungen," by Eysell, Cand. Med.. 
Arch. f. O. Vol. V. 1870. 



50 The Function of the Sound Conducting Apparatus. 

horn of the stirrup is the fulcrum. The large part of the foot plate of 
the stirrup which is in front of the axis b c moves towards the drum cavity, 
the smaller rear part towards the labyrinth. According to Eysell the 
movement towards the outside on the front pole is eleven times larger 
than the inward motion at the rear pole. I verified this kind of motion 
of the stirrup by actual measurements by means of the labyrinth mano- 
meter, and found the only difference to be that the axis ligament of the 
stirrup runs a little obliquely from the rear and upward to forward and 
downward. 

Politzer established the antagonism of the two muscles in the drum 
cavity long ago. It is supported by their different innervation, the stape- 




Fig. 26. 

Section through the stapes and the pelvis ovalis, according to Eysell. 
a anterior, b posterior part of the lig. annulare ; c tendon of the M. stapedius. 

dius muscle from the facial nerve, the tensor musae from the motor 
branch of the trigeminus nerve. The stapedius muscle, by stretching, 
thus elongating the chain of ossicles, is able to move the chain of ossicles 
and the drum membrane outward and thereby increase its convexity in 
opposition to the tensor muscle. 

Considering the cooperation of the two muscles we find that the 
tensor muscle tightens the axis ligament of the hammer, while on the 
other hand the stapedius muscle alone tightens the axis ligament of the 
stirrup on account of the course of its tendon which is from the rear 
and somewhat medial. This bracing effect is increased by the pressure 
which the traction of the tensor muscle exerts simultaneously against 
the head of the stirrup through the processus lenticularis of the long 
process of the incus. Both muscles acting simultaneously, the part that 



The Function of the Sound Conducting Apparatus. 51 

is stretched the least is the anterior upper part of the ligamentum annu- 
lare, which is also the broadest and thinnest part of the ligament. Here 
the action of the tensor is opposed to that of the stapedius muscle. The 
tensor muscle is six times as large as the stapedius muscle. This differ- 
ence in size is completely counterbalanced by the very favorable inser- 
tion of the tendon of the stapedius muscle, as compared to the tensor 
which acts high up on the handle of the hammer. The processus lentic- 
ularis starts horizontally from the long process of the anvil. It forms 
also a very obtuse angle which is open towards the rear and which dur- 
ing traction of the tendon of the stapedius becomes even more obtuse, 
until it is nearly a straight line. There is therefore the same principle of 
action as in the printer's press. . 

v. Helmholtz in studying the joint between the hammer and incus 
found that, on account of a catching tooth on the hammer as well as on 
the incus, they act like the stem in a stem winding watch, inasmuch as 
the hammer in each motion inward acts together with the incus like a 
solid bent lever, while whenever the hammer moves outward the incus does 
not follow its motion, v. Helmholtz sees in this (no doubt correctly) a 
protection against a pulling of the stirrup which might occur whenever 
the air in the drum-cavity is compressed, as in blowing the nose. The 
very minute movements inward and outward, which are produced by the 
sound waves, act differently. Here the antagonistic action of its two mus- 
cles presses the glenoid surfaces of the joint between the anvil and stirrup 
against each other, so that even in a very small movement outward they 
cannot separate. This effect extends backward to the joint of the ham- 
mer and incus. Experiments with the manometer convinced me of the 
accuracy of this postulate. 

Firstly. The sound conducting apparatus on account of all these 
deliberations must be considered as a mechanical combination, the parts 
of which are connected in such a manner that to each motion of one part, 
the others have to make a corresponding motion. This chain transmits 
the inward and the outward movements of the drum membrane. Sec- 
ondly, the anterior upper part of the ligamentum annulare must be con- 
sidered as a membrane which is just as movable and just as well balanced 
as the drum membrane itself, on account of the co-operation of the whole 
apparatus. The movements of the drum membrane are transmitted to the 
foot plate of the stirrup and the ligamentum annulare through the chain 
of ossicles without any loss. They arrive there smaller but so much 
stronger, as through a pantograph. Politzer also "sees an important 
function of the muscles in the tympanic cavity in offsetting the changes 
of tension of the ossicles and the contents of the labyrinth, caused by 
changes of air pressure ; in other words, to regulate the tension of the 
apparatus of hearing." (Arch. f. Ohrenheilkunde 1869 Vol. V Page 23.) 

Observations of the diseased ear gave us further particulars of how 



52 The Function of the Sound Conducting Apparatus. 

the sound conducting apparatus transmits the sound-waves from the 
air to the end organs of the acoustic nerve. 

The manifold defects and fixations of different places of the sound 
conducting apparatus which we meet with have one common effect. 
They do not diminish hearing uniformly throughout the sound scale, 
we find a greater decrease in the hearing of the lower part of the sound 
scale, the more so the lower we descend. We find a complete loss of 
hearing of a smaller or larger part at the lower limit, which may amount 
to one or several octaves, as soon as there are serious anomalies of the 
sound conducting apparatus. On the other hand hearing is the less inter- 
fered with in anomalies of the sound conducting apparatus, the higher 
in the sound-scale we climb. The complete loss of the drum-membrane, 
the hammer and anvil notwithstanding, the highest part of the sound 
scale which is produced by the Galton whistle for example, can be heard 
nearly to its full length and to its normal upper limit, with the stirrup 
alone. The upper limit of hearing may also remain intact in partial fixa- 
tion of the foot-plate of the stirrup. A considerable remnant of hearing 
at the upper part of the sound scale may be left even when all of the 
stirrup is absent and replaced by a movable occluding plate. Deafness 
with an intact labyrinth results only when both windows are immovably 
closed (Habermann). 

The slightest overbalancing, on the other hand, of one or another of 
the sound conducting apparatus is sufficient to destroy the hearing of the 
lowest one and a half octaves. Examples are the slight increase in the 
tension of the drum membrane in swallowing with the nose closed, or the 
wilfull contraction of the tensor tympani muscle, or a small traumatic 
perforation of the drum-membrane. 

All the different changes of the sound-conducting apparatus, as soon 
as they alter its well balanced condition, have without exception the same 
effect, they interfere with the conduction of the lower sounds from the 
air to the labyrinth ; the more so the deeper in the sound-scale we de- 
scend. 

We are therefore justified in the statement that it is the function of 
the sound conducting chain to transmit the large slow and weak move- 
ments, which are produced in the air by the lower half of the sound scale 
smaller, but stronger to the column of fluid in the labyrinth. This is 
accomplished by the wonderful lever apparatus consisting of drum-mem- 
brane, hammer and anvil. The rythmical vibrations of the air in the 
higher parts of the scale are smaller and more rapid. They need this 
lever apparatus less, the higher in the sound-scale they are. It seems that 
the highest part of the sound-scale does not need this apparatus at all, 
it is transmitted to the labyrinth through any plate which occludes the 
oval window. 

I want to describe to you another function of the ear equally as 
wonderful as the accurate reception and transmission from the air of 



The Function of the Labyrinth. 



53 



18 islands or patches of hearing 7 gaps in the range of hearing 



Galton Whistle 



Five Stroked Octave 



Four Stroked Octave 



Three Stroked Octave 



Two Stroked Octave 



One Stroked Octave 



Small Octave 



Capital Octave 



Contra Octave 



Subcontra Octave 



N° 


1 


2 


3 


«, 


5 


S 


7 


8 


9 


10 


11 


12 


O 


1*1 


15 


16 


n 


16 




1 


2 


3 


t§ 


5 


s 


7 


1 


















































2 


















































3 




































































































5 


















































6 




































































































e 


















































9 


















































10 


















































11 


















































12 


















































f-m 


















































e w " 




































































































a .„„ 




































































































C"'" 


















































■ h"" 








































































































































































































.0"" 




































































































f* 


















































e- 




































































































a- 




































































































C"" 


















































h"' 








































































































































































































0'" 




































































































F'" 


















































e'" 




































































































&■■ 




































































































C" 


















































h" 






























































































a" 




































































































<7" 




































































































t" 


















































t" 


































































































d" 




































































































C" 


















































h' 




































































































a' 




































































































Jii- 




































































































f 


















































e' 




































































































a' 




































































































c 


















































h 




































































































a 


































































































V 




































































































r 




















































































































































d 




































































































c 


















































H 




































































































A 




































































































G 




































































































t 


















































l 




































































































I) 




































































































c 


















































H' 




































































































A 




































































































G' 




































































































F 1 


















































f 




































































































!)• 




































































































c- 


















































3D 


















































26 


















































26 


















































2U 


















































22 






































- 












20 
















































16 
















































16 










| 














\ 























Fig. 27. 

Fig. 27. The islands or patches of hearing and the gaps in the range of hear- 
ing in the ears of 59 deaf-mutes whom I examined in 1898. 



54 The Function of the Labyrinth. 

even the weakest sounds of every pitch. It is able to distinguish the pitch 
itself, which ability, especially in the middle part of the sound-scale, 
amounts to the accuracy of differentiating the numbers of vibrations to 
fractions of one vibration. Most wonderful of all, it is able to perceive 
separately all different sounds and noises which act upon it simultane- 
ously. 

v. Helmholts explained this faculty of the ear by establishing the 
theory of the mechanical analysis of impressions of sound in the cochlea, 
which you know from physiology, viz. : 

The fibres of the zona pectinata in the basement membrane of the 
cochlea are stretched out similarly to the cords of a piano. They increase 
in length nearly twentyfold from the shortest fibres in the basis convo- 
lution, to the longest in the cupola of the cochlea, according to the 
measurements by Hensen. v. Helmholts recognized resonators for the 
whole scale in these cords, which are stretched by the complicated stretch- 
ing apparatus of Corti's organ and transmit their vibrations directly to the 
layer of rod-shaped cells of the acoustic nerve. Any number of sounds 
which reach these cords simultaneously will cause a corresponding num- 
ber of them to vibrate simultaneously. The perception of the highest 
sounds is accomplished in the basement coil, and of the lowest sounds in 
the cupola of the cochlea, according to this theory. 

It is one of the most beautiful and most important tasks of the otol- 
ogist to verify by observing the diseased ear the accuracy of this theory, 
which has become so indispensable for understanding the act of hearing : 

There are a small number of pathologic anatomic findings where 
the local destruction of the cochlea coincided in the living with the loss 
of hearing of a certain part of the sound-scale. 

In the living we find another valuable corroboration of v. Helm- 
holtz's theory by reviewing the great number of partial defects of hear- 
ing which we find by means of accurate functional tests with the contin- 
uous sound-scale in very deaf people, and in such as have no hearing for 
speech. You will find in fig. 27 a graphic illustration of the islands and 
gaps of hearing in the course of the sound scale and the large defects at 
its lower and upper ends as I found them in functional examinations of 
the pupils of the Central Institution for deaf mutes in Munich in 1898. 

The heavy black lines give the extent of hearing for each ear. You 
see from this illustration that defects of hearing may be found every- 
where in the sound scale, at either end and in the middle. Fragmentary 
elements of hearing even as small as one or two half tones may prove 
deficient or may have been preserved. As a general rule however hear- 
ing for a greater or smaller succession of tones is either lost or preserved. 
More than one or two circumscribed defects of hearing are rarely found 
within the remaining succession of sounds. The defects of hearing in 
the ear of the deaf mutes were actually found with those characteristics 
which zee had a priori to expect, if v. Hclmholtz's theory prevailed, 



The Function of the Labyrinth. 55 

namely, that the elements of hearing are spread over an extensive ana- 
tomical field in diatonic succession. A comparison will make the idea 
clearer. The destructions which we found in our examinations are lo- 
cated in the cochlea. They appear exactly as though one or several pieces 
of plaster had fallen from the ceiling on the strings of a piano and had 
destroyed a series of strings either in the middle or at one or both ends. 

A better and more convincing confirmation of v. Helmholtz's theory 
can hardly be conceived than the demonstration of so many well cir- 
cumscribed defects of hearing, as lie before us. 

We are justified therefore in locating the destructions in the cochlea 
exactly where we expect them according to v. Helmholtz's theory, when- 
ever we find such defects of hearing in examining patients. 

It explains most completely even today all the facts established by 
observation, although a number of new theories have been advanced. 
There is therefore no reason to dwell upon the latter. 

The researches of Kreidl seem to show that fish who have no cochlea 
do not hear. This makes it -plausible that in the phylogenetic series of 
animals hearing only begins where the cochlea begins to be developed 
as a part of the labyrinth. 

The remainder of the labyrinth serves other functions. Flour ens made 
many experiments on animals which became the starting point for a great 
many others, and established the following facts: the semicircular 
canals and their ampullae, are organs of equilibrium, which give us in- 
formation concerning rotation in the three dimensions of space. The 
end organs of the nerves in the sacculus and utrilicus with their otolith 
keep us informed as to the position of our head in rest, and as to changes 
of velocity of movement in a straight line, according to experiments of 
Breuer and others. 

Studies in the pathology of the ear have given us much valuable 
information as to the importance of the labyrinth, especially of the semi- 
circular canals for our knowledge as to our position and the position of 
different parts of our body in space, furthermore about the relation of 
irritation and paralysis of its nerves to the reflex movements of the eyes. 
We have learned to draw conclusions as to the location of irritation in 
the labyrinth from the presence of dizziness and nystagmus in differ- 
ent directions. We are also justified in inferring the destruction of end 
organs of nerves in the ampullae and vestibulum from the absence of 
dizziness and nystagmus during and after rotation of the body around 
its own axis. 



LECTURE VIII. 

Examination of Hearing by Means of Tones. 

A. In Air Conduction. 

Gentlemen: — Physics makes a distinction between tones and noises. 

New investigations made it very plausible that all noises are nothing 
but a mixture of tones, the pitch of which is very close together, there- 
fore they are unharmonious. Some of them are very low. I might men- 
tion the wind instruments as an example of the accuracy of this explana- 
tion of noises. They are resonators if you consider them as a whole, of 
different size for each different pitch. Upright vibrations of the air in 
them are caused by the noise of blowing. All tones which the instrument 
is able to produce must therefore be contained in this noise. 

It is of fundamental importance for our examination of the function 
of hearing that all noises can be placed in the line of the sound-scale. 
We have therefore completely examined the hearing, as soon as we know 
quantitatively the hearing for all tones, and do not need to care for the 
noises. 

These considerations, besides a number of others, induced me to con- 
struct a series of instruments which produce all the sounds the 
human ear can perceive. I showed them in 1890 to the otological section 
of the international congress of physicians in Berlin. 

Prof. Dr. Edelmann of Munich who is known all over the world for 
the manufacture of the finest instruments of precision, improved the 
"continuous sound-scale" as he called it so that it now consists of ten 
tuning forks with movable weights at their prongs, and three covered 
whistles with movable pistons. Tzvo points had to be considered in its 
manufacture. 

Firstly, all tones which the human ear is able to perceive ought ac- 
tually be contained in it. This is accomplished by moving the weights 
of the tuning forks or the pistons of the whistles, by which method any 
audible number of vibrations may be produced. To those who are 
not musical an engraved scale of half-tones shows the pitch. 

56 



Tests of Hearing by Air-Conduction. 57 

The second task is to create as clear tones as is possible, i. e., to 
exclude the overtones which all our musical instruments possess, and 
which give them their individual character of sound. Weighted tuning 
forks and covered whistles were suggested by v. Helmholtz long ago as 
instruments which serve this purpose best. It is well nigh impossible in 
Edelmann's weighted tuning-forks, no matter how hard they are struck, 
to detect a trace of overtones even close to the arc, which is the place 
where they would be heard the easiest. The whistles were made free of 
overtones by regulating the width of their mouths according to the pitch. 

The sounds of the tuning forks at the lower end of the scale seem 
weak to the ear which is not used to hearing clear tones. The large 
vibrations with the heavy weights correspond in reality to a considerable 
amount of energy, which you will notice if you hold the fork close 
enough to the ear. The large number of deaf-mute pupils who are able 
to hear even the lowest end of the sound scale x furnish the best proof 
that the sounds of the continuous series are strong enough to consider deaf 
all those people who do not hear them. We need stronger sounds just 
as little as the ophthalmologists need the sun instead of diffuse daylight 
in order to prove blindness. 

The correct use of these tuning forks is not very easy. To strike 
them in a sufficiently elastic manner has to be learned like the playing of 
a musical instrument. Think for example of the difficulty of playing the 
kettle-drum. The lower forks are best struck with the ball of the thumb, 
the higher ones with a rubber hammer. 

The healthy ear perceives, according to my examinations of a great 
many individuals from 12 double vibrations, ("vibrations doubles" ab- 
breviated v. d.) or even a little less up to 41,000 vibrations. (0.5 of the 
third whistle, which is a Galton whistle, modified by Edelmann gauged 
with Kundfs glass tubes, containing lycopodium powder.) 

In older people the upper limit becomes somewhat lower, about 2.0 
of the Galton whistle, which is 23,500 vibrations. The lower limit 
remains the same, that is 12 vibrations. 

We test the diseased ear by passing the sound-scale in small intervals 
of pitch before the ear. We find out whether it is heard throughout by 
air conduction, or whether there are any deficiencies at either end or in 
the course of the scale. We talk of "gaps" whenever circumscribed por- 
tions in its continuity are not heard. We call it an "island" when only 
one section of the sound scale is heard not larger than three octaves. 
The recording of these remnants of hearing can be accomplished very 
easily and clearly, as you see from fig. 27, which shows the islands and 
defects which were found in 1898 in my examinations of the pupils of 
our deaf-mute institution. 

We have just now described the examination of the quality of hear- 



1 In fig. 27 I only gave a diagram of the hearing of pupils who heard but a limited extent of 
the sound-scale (islands), or where interruptions in the continuity of the scale were found (gaps). 



58 



Tests of Hearing by Air-Conduction. 



ing which reveals the total loss of hearing of some parts. A complete 
examination has to consider also the quantity which shows the accuracy 
of hearing in different parts of. the sound-scale. 

We analyse the function of all the elements of hearing which consti- 
tute Corti's organ, by examining the quality and quantity of hearing 
within the above described limits and with the above stated supposition 
that all noises are but a sum total of tones. 

We measure the time that each tuning-fork is heard in order to ex- 
amine the quantity of hearing. 

First, every one of us must determine how long each tuning-fork 
of his own set, after giving it the hardest shock, can be heard by the nor- 
mal ear. 



100 



225 1 175 [203 \ 169 \209\ 273X270 



Duration of hearing 
in seconds. 




Pitch. ^JtZtfos 

Fig. 28. 
The normal durations of hearing of my continuous series of sounds. 

It requires too much time to do this for all tones of the scale. It 
is sufficient to confine the determination of the duration of hearing to the 
octaves of c, and in the most important part, upward from c 1 to the tones 
of c and g. We remove the weights from the forks, since with the 
weights they do not sound long and the results are inaccurate. The 
sound-scale, when the weights are removed, consists of c and g forks, to 
which up to c v inclusive, forks without weights must be added. (The low- 
est fork is Ei instead of Ci without the weight.) We need not pay any 
attention to the numerous overtones of the forks without weights, since 
for the determination of the duration of hearing, the end of the duration 
of sounding has to be ascertained, at which time the overtones have long 
disappeared. 



Hearing Tones by Air-Conduction. 



59 



We hold the handle of the fork lightly between the first three fingers, 
prongs downward after striking them very hard. We approach it to the 
ear of the patient at irregular intervals, longer at first and shorter later 
on. Touching even of the hair has to be avoided, and so has the possi- 
bility of the patient seeing the fork. He has to raise a finger every time 
he hears it till he does not hear it any more, even if the fork is held 
as close to the ear as possible. 

The tuning-forks of different pitch do not sound equally long to the 
normal ear. You will find a diagram in fig. 28 of the duration of hear- 
ing of my own c and g forks without weights. 

The time of sounding from g 11 upward decreases very fast as you 
see. The time above c v would be so short that it could not be measured. 




100 

Qtl 


E1 


c 


c 


c* 


c" 


g"\c ( " 


gill 


C* 


9* 


ex 


rn 










































70 












! 










hi) 
^0 








— I — 


H= 










40 
30 
20 






























m 

















Right. 



Left. 



Fig. 29. 
Diagram of the remnants of hearing in the right and left ear of a deaf-mute. 

The darker parts show percentages of the normal duration of hearing, the black parts the corres- 
ponding figures obtained by taking into account the amplitudes of each tuning fork {See Fig. 30). 

The determination of the duration of hearing is the less accurate 
the shorter the time is during which a fork sounds. A mistake of 2 
seconds in a c 1 fork, for example, which is heard for 273 seconds does 
not make any difference, while it is one-fourth of the whole duration 
of hearing of c v sounding 8 seconds. 

It would be wrong to try and make all tuning-forks uniform, so that 
all forks of the same pitch would have the same duration of hearing. It 
could only be accomplished to the detriment of the best forks which can 
be produced. The longer a tuning fork vibrates the more reliable are the 
measurements taken with it. Take for example a shortening of 20 sec- 
onds for a tuning fork c 1 sounding 273 seconds which can easily occur 
on account of the day's noise, it is a mistake of 7% only. A mistake as 
small as that can not be avoided in our hearing tests which are made in 
daytime. Our examinations with speech show sufficiently that we have 



60 



Hearing Tones by Air-Conduction. 



to be satisfied if, in several repetitions of the same test, the difference is 
not more than 10%. 

The examiner, after having determined the duration of hearing for 
his forks without the weights on a number of people with normal hear- 
ing, may record the duration of hearing of a diseased ear for all c, or c 
and g forks in per cents of the normal, according to Hartmann. He may 



too 

90 


a. 












































SO 
























70 
























60 








\ 
















SO 










\ 














W 












X 












30 
























20 






\c 


















40 


















\ 



























\ 


ff. 



100 




10 

42.2 



zo 

22.6 



30 



70 



80 

1,9 



90 100 

5,83 0,32 



W SO 60 

Amplitudes. 
13.5 9.2 6,5 4,5 3,1 
Acuteness of hearing in fractions of 1. 
0,006 0,015 0,024 0,035 0,049 0,071 0,107 0,15 0,39 1 

Fig. 30. 



enter the results of all the forks in a diagram, which we may call "field 
of hearing." 

You find for example in fig. 29 the diagram of hearing of the right 
and left ear of a deaf-mute. He has sufficient hearing in his left ear to 
follow instructions of hearing, which is not the case in his right ear. This 
gives us a general idea of the extent of hearing in the deaf ear, upon 
which we can base a reliable judgment about the possibility of hearing 



Hearing-Tests for Tones by Air-Conduction. 61 

speech. My examinations of deaf-mutes with remnants of hearing 
showed this sufficiently. 

The numbers which are obtained this way can be used of course only 
for comparison. The real number for every single tone is not by any 
means accurately expressed. 

Fig. 30 will help me to explain why. We measure the time that a 
tuning fork is heard, which is an arithmetical proportion like the line 
a b d in fig. 30. The amplitudes of the vibrations however decrease very 
fast in the beginning, later on more slowly, in a nearly geometrical pro- 
portion, as the line a c d in fig. 30 shows {Jacob sen, Barth, Thiry). 

The actual power of hearing of a diseased ear decreases at a much 
greater ratio than the time during which it hears the tuning fork. There- 
fore we can not measure the power of hearing by the time an ear hears 
the fork and compare it with the normal. The actual power of hearing 
is much smaller than the time, as may be recognized very easily by 
comparing the curve a c d which shows the decrease of the amplitudes 
of the vibrations, with the straight line a b d in fig. 30, which marks the 
progress of time. The next few paragraphs will illustrate these points. 

The curve a c d shows the decrease of the amplitudes of vibration 
after the fork is struck very hard, till it can not be heard any longer by 
the normal ear. For the construction of this curve we could use only 
the lowest tuning forks, whose vibrations are very large and whose ampli- 
tudes can be measured comparatively easily until the fork can not be 
heard any longer. The abscissa of the diagram show the duration of 
hearing for all forks, reduced to the number of 100. The ordinates give 
the proportion of the amplitudes and the time of hearing after the fork 
has been struck hard, the first amplitude being set=ioo. 

You see from fig. 30 that after one-tenth of the whole time during 
which the fork is heard, the amplitude is only 42.2% of the largest ampli- 
tude, and after one half this time only 6.5%, etc. 

Supposing that the height of the amplitudes were simply inversed 
proportionate to the accuracy of hearing, we would be able to calculate 
in an easy manner the real degree of accuracy of hearing for any moment 
from this curve of averages. The lowest row of numbers of fig. 30 
shows this, accepting normal hearing as equal to 1. 

Ostmann solved the laborious task of measuring directly all the 
amplitudes of the higher tuning forks (as far as g) till they could not 
be heard any longer. The values of hearing which we found by calcu- 
lation, and which by us were called approximately correct only, were 
entirely rejected by Ostmann, Schmiegelow and others. Their reasons 
for doing so are, firstly, that they found different curves for the decrease 
of the amplitudes of vibrations in different tuning-forks, secondly, that 
the energy of a vibrating tuning fork does not correspond to the simple 
amplitude, but to its square. 



62 Hearing-Tests for Tones by Air-Conduction. 

There is this to be said about the first reason. The differences of 
the curves of the decrease of the amplitudes of forks of different pitch 
and of different forks of the same pitch are considerable only directly 
after the strongest shock, and become smaller probably as soon as the vi- 
brations effect an equilibrium between the interior resistance of the fork 
and the surrounding elastic medium, viz : the air. The strongest vibra- 
tions in the beginning are important for practical measurements in the 
very deaf only, where hearing of speech is absolutely excluded. There is 
no practical value in making distinctions of such high degrees of deafness. 

This must be said about the second point-: We are not justified 
in basing our calculations of the accuracy of hearing on the square of the 
amplitude, since the whole of the energy of the vibrating tuning fork 
does not act on our ear. It is even very probable that a smaller part of 
the maximal vibrations is effective than of the later vibrations, since the 
sound conducting apparatus can not as well follow the vibrations with 
large amplitudes as it can those with smaller ones, for the transmission 
of which it is much better adapted. 

The extremely small intervals with which Ostmann and Schmiege- 
lozc want to measure the acuteness of hearing do not correspond to the 
rough estimation of intensity of sound, which our ear is able to make 
according to my experience. 

The acumen of hearing of the normal ear for tones of different 
pitch varies greatly. The physicist JJ'ien established by means of very 
interesting experiments with the plate of the telephone, that our ear is 
much more sensitive for tones of the middle part of the sound-scale than 
for those at either end. The fact is very important for an accurate judg- 
ment of the value of defects of hearing especially in the middle part of 
the scale where, as we shall see, the tones of speech are to be found. 

I do not think it is suitable for the purpose in view, that Ostmann, as 
he did lately, take also the curves that Wien found for the different hear- 
ing of tones of different pitch into consideration for the calculation of 
acumen of hearing. It would confuse matters very much if we did not 
take the hearing of the normal ear as the standard and=i, for each tone 
be it high or low. There are different qualities of the elements of the ear, 
and we must refrain from comparing the quantity of sounds of different 
pitch with each other, at least in our practical examinations. 

These complicated questions are just at present the center of interest 
in otological literature. They can not be passed without mention. We 
shall see, in discussing the examinations of hearing especially of deaf- 
mutes, that a determination of that duration of hearing in per cents 
of the normal for the c tuning forks (and maybe g). is entirely sufficient 
to judge accurately of the hearing for speech. The high theoretical value 
of an objective measure of hearing for some diseases and their differen- 
tial diagnosis is not contested. 



Hearing-Tests with All Sounds of the Scale are Seldom Necessary. 63 

The examination of all ear patients with all sounds of the scale, as 
was described, cannot be carried out, if, for no other reason than because 
of the loss of time. 

It is however absolutely necessary in the examination of all pupils 
of deaf-mute institutions. The accurate establishment of the quantity 
in remnants of hearing which are present in a great number of deaf- 
mutes, decides whether their ear can be used for future instruction. These 
are assigned to separate classes for instruction by means of hearing. The 
others have to learn to understand speech by observing the mouth of 
the teacher, and speaking by instruction in articulation. 

The examination with the whole scale is necessary for the establish- 
ment of complete deafness in one or both ears, 

In one sided deafness the normal ear can be excluded with greater 
difficulty the higher in the scale we ascend. The apparent picture of 
hearing of the deaf ear will be met with and studied again in the descrip- 
tion of necrosis of the labyrinth. Such cases must of course be examined 
with the whole sound-scale in order to find out defects or islands. 

In -very serious suppurations of the middle-ear the examination with 
the whole sound-scale may be of great importance for our diagnosis and 
therapy. It will help us to decide whether the labyrinth is still intact, 
or whether the process has penetrated through its wall, and how much 
further it has advanced. 

There are therefore only the patients with the highest degrees of deaf- 
ness which require an examination with the whole sound-scale. The 
duration of hearing for tuning forks in them is generally very much 
shortened. The time therefore which is consumed by a complete exami- 
nation with the sound-scale is not too long. 

We can limit our examinations with the sound-scale by air conduc- 
tion to the establishment of total defects in the lower and upper ends of 
the scale in all cases of deafness of medium and minor degrees. The 
functional tests will help us to make a differential diagnosis in all cases 
of deafness with negative findings of the drum-membrane. They are fin- 
ished in a few minutes. The examinations with speech and by bone con- 
duction give us in practice usually a sufficient amount of information to 
render superfluous the examinations with the whole sound-scale, which 
require so much time. 

Nobody expects that each general practitioner own all the instru- 
ments of the sound scale nor make examinations with them. I deem it 
necessary however to give them at least a general idea of the existence 
and the importance of a method of examination which allows us to ana- 
lyze the function of the organ of hearing so completely. 

It may be desirable however for general practitioners who have to 
examine ear patients once in a while or even give expert testimony in 
court, to have one or two low forks with weights, which contain the 
sounds from G 2 to D 15 and D x and A x . They put them in a position to es- 



64 Hearing-Tests with All Sounds of the Scale are Seldom Necessary. 

tablish a defect of hearing at the lower limit which is a constant rinding in 
diseases of the middle-ear. A Galton whistle furthermore will enable 
him to find out defects of hearing at the upper limit of the sound scale, 
which are frequent in diseases of the inner ear. The practitioner without 
these two means of examination has to desist from making any diagnosis 
in all of those numerous cases of deafness with negative findings in the 
drum-membrane. 

One or two more tuning-forks without weights an a 1 , and an A are 
furthermore necessary for the examination of air conduction. They lie 
in the course of the scale and are indispensable to the practitioner who 
wants to examine bone conduction. 



LECTURE IX. 
Examination of Bone Conduction. 
Course of the Examination. 

Gentlemen: — Two tuning-forks are usually sufficient for the exami- 
nation of the bone conduction. 

The first one is the middle tone of the scale, a common a 1 tuning- 
fork which is also used by musicians. The second fork is two octaves 
lower, a large A fork without weights; a G or c fork of the continuous 
tone series without the weights may be used instead of A, if it sounds long 
enough in bone conduction. 

A few remarks about the physiological condition of bone conduction 
have to precede an explanation of its use for diagnostical purposes. 

Our usual act of hearing is performed exclusively by means of the 
sound conducting apparatus. Even the small fraction of very strong 
sound waves which passes from the air to the surface of the skull is 
perceived only to such an extent as it is able to cause transverse move- 
ments of the whole sound conducting apparatus. 

The labyrinth and the sound conducting apparatus vibrate together 
with the other bony parts whenever the sounding vibrations of a solid 
body are transmitted directly to the skull. This occurs whenever a 
sounding tuning-fork is pressed against some point of the skull or any 
distant part of the skeleton. Lucae, Politzer, and others proved by ex- 
periments on the cadaver, that the movements are transmitted in this 
way. 

It is very probable that we perceive, in air as well as in bone conduc- 
tion, only those sound waves which, on their way to the labyrinth, have 
passed through the sound conducting apparatus. The sound waves which 
reach the labyrinth directly, i. e., without appropriate intervention of this 
apparatus, are to us inaudible. 1 

The function of the sound conducting apparatus for the perception 
of hearing consists therefore in transforming the longitudinal sound 
waves of the air, as also the longitudinal waves which pass directly 
through the skull, into transverse vibrations of the sound conducting ap- 



x Weitere Untersuchtmgen uber Knochenleitung. Z. f. O. XL VIII, 1 and 2. 

5 65 



66 Weber's Test. 



paratus (as a whole together with the column of the labyrinthine fluid). 
These transverse vibrations alone are able to effect such concomitant vi- 
brations of the end organs of the acoustic nerve, as can be perceived. 

Accepting this theory, we will understand an observation which con- 
stantly can be made on the diseased ear but which at first sight appears 
very odd. It is however supported by a great number of physiological 
experiments on the normal ear : 

In all diseases of the sound conducting apparatus we do not find a 
diminution of hearing by bone conduction, which corresponds to the 
diminution by air conduction, but the opposite, we find an increase of 
hearing by bone conduction over the normal, while hearing is equally 
bad for air and bone conduction in diseases which are confined to the 
nervous apparatus. 

There are three methods by which we test the improvement or de- 
terioration of bone conduction respectively. 

Weber's test has been known the longest and is used the most. The 
handle of a vibrating tuning fork is placed in the sagittal line on the ver- 
tex of the head. The patient has to decide with which ear he hears it 
best. We use for this test an a 1 or aA tuning fork. Ed. Weber estab- 
lished the fact that it is sufficient to close either external canal with 
the finger to increase hearing by bone conduction in that ear. 

The tuning fork which is placed on the vertex of patients with one- 
sided affections of the sound conducting apparatus, or in whom the affec- 
tion is more developed on one side in an analogous manner is heard ex- 
clusively in the affected, or at least better in the more affected ear. This 
localization of the sound in the diseased ear in most cases strikes the pa- 
tient at once. Children especially almost always give accurate informa- 
tion in this respect. The idea that their diseased ear must hear worse 
under all circumstances is often so powerful, especially in patients who 
belong to the better educated classes of adults, that their statements in the 
beginning are wrong. We can however easily convince ourselves of their 
mistake by repeating the experiment while the patient shuts his good or 
less affected ear with the finger. We know that he does not observe 
correctly when he says, now "of course" he hears in the diseased ear. 

In one sided diseases of the inner ear the decision for many patients 
is much more difficult. It does not occur very rarely that even after ex- 
foliation of sequestra of the labyrinth, the patient thinks he hears the 
tuning fork which is placed on his vertex, in the deaf ear. This evident 
error of the patient has led a number of authors to the risky assertion 
that the acoustic nerve alone is able to perceive sound waves. 

The statements as to localization of diseases of either inner ear 1 are 
correct, at least in the majority of cases, according to my own examina- 



1 We call (here and in the next paragraphs,) diseases of the inner ear the changes in the laby- 
rinth, diseases of the acoustic nerve, its cerebral tracts, and its part of the cortex. The findings of 
the functional examination as to bone conduction etc. are the same in all of them according to my 
examinations. 



Schwabach's Test. 67 



tions which extend over many years. The sound is heard of course in 
the healthy or better ear, provided that the sound conducting apparatus 
is not changed. It is not very rare however that patients declare they are 
not able to locate the sound. 

More reliable than in Weber's test are the statements of the patient 
in the next two tests which we use in the examination of bone conduction. 
The second test is the comparison of the duration of bone conduction of 
the diseased car with that of the normal car {Schwabach's test), the 
third, the comparison of the duration of bone conduction with the dura- 
tion of air conduction in the diseased ear (Rinne's test). 

We measure the duration of bone conduction for two tones of dif- 
ferent pitch with tuning forks without weights, A and a 1 , or neighboring 
tones. The tuning fork is placed on the vertex of the patient after it was 
struck as hard as possible. He has to indicate the moment when the 
sound ceases. The duration of hearing thus found is compared with the 
duration of hearing by bone conduction in a healthy ear with the same 
fork. The positive or negative difference is entered into our records as 
Schwabach test -f xor — x or as ± o (if the patient hears it just as 
long as the normal), or simply as o, (if he does not hear it at all). 

The manner in which the tuning fork is struck becomes irrelevant if 
we measure the difference of time directly. Namely, in prolongation of 
bone conduction, we place the tuning fork, after it has stopped sounding 
in a normal hearing ear, to the ear of the patient. In shortening of bone 
conduction we do the opposite, that is we measure the time that the fork 
is heard by the normal after it is not heard any longer by the diseased 
ear. 

The duration of bone conduction need only be ascertained from the 
vertex for both ears at the same time and not for each ear separately from 
its mastoid process, because in placing the tuning fork on the mastoid pro- 
cess, the other ear can be excluded but very incompletely. The preceding 
Weber's test has already revealed to us in which ear the fork is heard 
loudest. 

The prolongation of an A tuning fork, whenever there is an impedi- 
ment to the conduction of sound, is greater than for a 1 . It occurs fre- 
quently that the Schwabach test with A fork shows a prolongation while 
a 1 shows a shortening of bone conduction, from which we draw the con- 
clusion that the inner ear also is affected. 

The determination of the time when a sensation ceases to be per- 
ceived, that is, the determination of the liminal intensity in physiology as 
in psychology is counted amongst the most reliable methods. Neverthe- 
less Schwabach's test although it is one of these determinations has sev- 
eral deficiencies. We do not need to hesitate in using it for diagnostic 
purposes whenever the duration of bone conduction from the vertex of 
the patient is very much shortened or altogether lacking, or on the other 
hand it is considerably prolonged, for 15 seconds and more. We have to 



68 Rinne's Test. 



depend however too much upon the gift of observation and the attention 
of our patient whenever the difference of time is relatively short one way 
or the other, positively or negatively. Both the gift of observation and 
the attention ought always be very keen on account of the many noises 
in our surroundings, which so closely resemble the sound of the low 
forks that are mainly used for Sclvwabach's test. 

A number of anomalies of the roof of the skull, consisting of trau- 
matic changes with depressions and adhesions of the bone to the dura, 
etc., seem to have some influence upon the bone conduction from the ver- 
tex, according to a number of observations made on patients of the psy- 
chiatric department. Bone conduction seems to be considerably short- 
ened in those cases normal hearing for air conduction notwithstanding, 
according to investigations of Wanner and Gudden. 1 

The most reliable results are furnished by the third test, which com- 
pares the duration of hearing of the diseased ear by bone conduction with 
that by air conduction. This test was described as early as 1855 by a gen- 
eral practitioner by the name of A. Rhine, who recognized its great im- 
portance for differential diagnosis of diseases of the middle and inner 
ear. 

An a' tuning fork is usually sufficient for Rinne's test. 

A sounding tuning fork, the handle of which is pressed against the 
mastoid process of a normal ear {Rhine put it against the teeth with sim- 
ilar success) is heard again when its prongs are brought close to the ex- 
ternal meatus, after the sound has died away on the mastoid. My a' 
tuning fork is heard by air conduction for 90 seconds. When its sound 
has died away on the mastoid process (that is, has stopped to be heard by 
bone conduction), it will be heard for 30 seconds longer by air conduc- 
tion if its prongs are held in front of the external canal. 

The air conduction under normal conditions is therefore far superior 
to bone conduction. The superiority of air conduction becomes more 
marked the lower the tuning fork we use. 

The Rhine test is the most sensitive indicator for all derangements 
of the sound conducting apparatus. Every change of equilibrium of this 
apparatus prolongs hearing by bone conduction at the same time that it 
shortens it by air conduction. The difference between bone conduction 
and air conduction which is measured in Rhine's test, diminishes very 
quickly whenever the derangement of the sound conducting apparatus 
progresses, and it soon becomes negative, i. e., the bone conduction be- 
comes of longer duration than air conduction, which is the opposite of 
the normal. We therefore mark it in our records as a negative number. 

We use the following abbreviations in our records of Rhine's test. 

We call t the time that the tuning fork is heard by az'r-conduction 
when it is struck hardest, till the sound dies away;#the duration of bone 
conduction. Rhine's test is the difference t — d. It mav have several 



') Die Schallleitung der Schadelknochen etc. "Neurol Centralbl." 1900. No. 19 to 21. 



Rhine's Test. 69 



modifications in different degrees of diseases of the middle and inner ear, 
viz.: 

Rinne's test, as it is found in the normally hearing, is recorded Rinne 
a '+3° (seconds). This number diminishes gradually with the increase 
of derangement of sound conduction. It remains positive until the dura- 
tion of bone conduction is just as long as the air conduction, which is 
t — #=o. This finding is recorded as Rinne a'±o. Whenever the de- 
rangement of sound conduction is still stronger, the tuning fork will be 
heard a number of seconds longer by bone conduction than by air conduc- 
tion, which we record as Rinne a' — the number of seconds found. This 
negative number may reach as high as 15 seconds. We find, when- 
ever the derangement of sound conduction is so great that hearing by air 
conduction is suspended altogether (while bone conduction may still be 
present, or even better than in the normal ear) that in the difference t — $ 
air conduction t=o. We record this condition as Rinne — #. 

The difference between air conduction and bone conduction remains 
about the same in diseases of the inner ear in which the sound conducting 
apparatus is not affected, the air conduction and bone conduction being 
equally reduced. Rinne's test remains +30 or a little less. The tuning 
fork fails first to be heard by bone-conduction, whenever hearing de- 
creases still further in diseases of the inner ear. In the difference t — # 
#=0 which we record as Rinne a'=+t. The tuning fork finally ceases 
to be heard by air-conduction only in complete deafness. 

The following series of expressions for Rinne's test embraces every 
possibility. 

Normal ear Small interference with sound conduction. 

Rinne=R=-{-$o sec. Rinne less than +30 sec. to Rdzo. 

Greater derangement of sound-conduction to loss of air-conduction. 

Rinne — x sec. to Rhine — S. 

Diseases of the inner ear exclusively. 

Minor degrees Higher degree to loss of bone conduction. 

Rinne=-\~2P sec - or ^ ess - Rinne =+t. 

It is an every day experience that the patient on an average finds it 
easier to give accurate information in Rinne's test than in either of the 
two others, Weber's and Schzvabach's test. We will not omit either of the 
latter in all cases of negative findings of the drum membrane, where the 
diagnosis depends exclusively upon them, especially since they require but 
very little time. 

Rinne's test is subject to a serious restriction in diseases of one ear, 
when the other is normal or nearly so, and whenever there is a disease of 
one middle-ear and the other inner ear. A short negative Rinne test 
is possible in disease of the inner ear, because normal or even pro- 



70 Physiologic Explanation of the Prolongation of Bone-Conduction. 

longed bone conduction of the other ear may mask the result of the func- 
tional tests. A positive Rhine's test of normal duration or nearly so, may 
be considered characteristical for diseases of the inner ear in one sided 
affections. 

The prolongation of bone conduction above the normal in changes of 
the sound conducting apparatus was accepted in our discussions as a fact 
pure and simple which we meet with in all our observations. Opinions dif- 
fer widely as to its physiological explanation. 

Here is the simplest idea of the different reaction of the sound con- 
ducting apparatus in conduction of sound through the air or through the 
bone: There is a different optimum of regulation for each of the two 
mechanisms. An uninterrupted conduction through the air is alone con- 
ceivable if the first link of the chain, the drum membrane, as well as the 
last link, the foot plate of the stirrup with the ligamentum annulare, are 
extremely well balanced, that is little stretched. Every alteration of this 
complicated apparatus will disturb the equilibrium of the antagonists and 
lead to a tighter stretching of the radial fibres, which form the ligamen- 
tum annulare. 

The conditions of bone conduction are different. They may be com- 
pared to a so-called string telephone. A sounding body which is con- 
nected with the ear by a string will be heard so much stronger, the tighter 
the string is stretched. Thus the vibrations, which are transmitted by 
bone conduction to the outer rim of the ligamentum annulare, are carried 
more easily from the rim to the foot plate of the stirrup, by means of 
these fibres, the tighter they are stretched on account of the disturbance 
of the equilibrium. 

The greatest facilities for simultaneous vibrations of the fibres of the 
ligamentum annulare in transmitting sound waves from the surrounding 
bone to the foot plate of the stirrup, are produced when the fibres are 
tightly stretched. The tight stretching interferes however with the trans- 
mission of sound waves which are received from the air. The interference 
becomes more effective the lower we descend in the sound scale. The 
whole sound conducting apparatus must be able to make large excursions 
to and fro in order to correspond to the large amplitudes of the vibrations 
of the lowest sounds which can be heard. 

This assumption explains both the preponderance of bone conduction 
and the loss of the faculty of hearing the lowest part of the sound scale by 
air conduction in diseases of the sound conducting apparatus. 

Reference to larger text books and monographs has to be made as to 
further methods of testing the hearing as with Gelle's test or Bing's test 
and others, which are used by some few authors only. 

Examination of Hearing by Speech. 

We finally consider the use of speech for hearing tests. 
There is hardly a better means, nor will there ever be any to obtain 
quickly a general survey of the ability of hearing. 



Tests for Hearing Speech. 71 

The elements of speech have a certain pitch just as well as any other 
noise. Dondcrs and v. Hehnholtz by means of resonators and other meth- 
ods ascertained the pitch of each vowel. 

Oscar Wolf established approximately the pitch of the consonants. 

The sound of the different letters is spread over 8 octaves, according 
to Wolf. The sound "R" is the subcontra octave, the sounds of "M," 
"N," "L," in the small octave, while the sibilant or hissing consonants are 
in the three to five stroked octaves. The results of these examinations, 
namely that the noise of each pronounced letter has a certain pitch, were 
further confirmed by the results of hearing tests in a great number of 
deaf-mutes with remnants of hearing. The letters which were pronounced 
could be heard only when the patient could hear those parts of the sound 
scale which contained the pitch of those letters. The letters "M," "N," 
"L," "U," "O," are never heard when hearing of the lower half of the 
sound scale is wanting; the letters "S," "sh," "th" and "J" never when 
the upper half is lost to perception. 

The part of the sound scale from b' to g" proved by far the most im- 
portant for hearing and understanding of speech, the sounds of most the 
vowels and consonants being contained in it. Children who did not hear 
tuning forks within that limit at all, or heard them for a very short time 
only after they were struck as hard as possible, were incapable of suffi- 
cient perception of speech to learn it by means of the ear, even though 
they had extensive remnants of hearing upward and downward from b' 
to g". 

To learn to speak in the natural way, that is by means of the ears 
can be expected whenever, combined with otherwise normal mental gifts, 
the hearing is relatively good for this small part of the sound scale (a 
duration of hearing of 10% of the normal) . The sounds of "S," "Sh," have 
to be learned by looking at the mouth of the teacher and by articulation 
exercises, whenever under these circumstances the upper part of the 
sound scale is wanting; the sounds "R," "M," "N" "L" when the lower 
part is wanting. 

On the other hand it is permissible in testing the hearing of hard 
hearing people by means of speech, to draw conclusions as to the pre- 
dominant affection of those parts of the sound scale in which the sounds 
of some pronounced letters lie, which are heard very poorly or not at all. 

The examination of hearing with speech takes much less time than 
tests with the whole sound scale. It is therefore practical to begin hear- 
ing tests of hard-hearing patients, except of partially hearing deaf-mutes, 
by tests with speech, in letting them repeat a series of words pronounced 
for them. 

Whispering has to be used for these tests, as conversation would be 
understood by the majority of hard-hearing people at such great distances 
that our rooms would not be large enough. 

We use conversation or loud speech for hearing tests only exception- 



72 Hearing-Tests by Whisper. 

ally whenever the whisper close to the ear is not accurately understood, 
or where, as happens often, there is a decided disproportion between un- 
derstanding whispering and loud speech. 

We use for the whisper the residual air only, that is, the air which 
remains in the lungs after a light, not forced, expiration, and whisper 
always at the same intervals of time, in order to obtain results which may 
be compared with each other. 

20 to 25 meters is accepted as the distance at which a normal ear 
can perceive all whispered words in a comparatively quiet room away 
.from the noise of the street. We shall see however that the distance is 
much larger for young people in an absolutely quiet room. 

I use the words of numbers from 1 to 100 for hearing tests as do a 
great many authors. They contain all the different sounds sufficiently 
complete. 

The criticism which was often made, that numbers may be guessed at 
so much more easily than other words will not stand. The main point for 
us is that any words we use for examination can be guessed at either 
equally well or equally badly. 

The results of our tests would become much more unreliable and 
variable if we used words which may or may not be familiar to our pa- 
tients, than if we know that all patients are equally well acquainted with 
all words used. Words without any meaning at all should be used if we 
wish to exclude all possibilities for combination. This cannot be recom- 
mended because we want to test the comprehension of the patient for the 
familiar language. Numbers are indispensable as test-words especially 
in younger children whose vocabulary is very limited. 

I became fully convinced during my "Examinations of infantile 
organs of hearing in schools" 1 that the test with numbers is completely 
sufficient. I found among 1,918 school children, whom I examined, using 
numbers exclusively, nearly 26 per cent who had only one third of normal 
hearing, or less (that is 8 meters or less) in one or both ears. The num- 
ber "100" which is the most difficult to understand was even excluded. 

The general result of this examination of large numbers of children 
is of so high a general interest, reaching far beyond the territory of otol- 
ogy that I reproduce here a diagram of it (compare fig. 31). 

The curve is very easily understood. It gives a survey of the hear- 
ing distance for whisper of 3,836 organs of hearing of children which I 
examined. The abscissas correspond to the distances in which whispered 
numbers (except 100) were understood. They are taken starting from 
16 meters or more downwards in equally decreasing distances, each being- 
half the distance of the preceding one. The numbers of ears which un- 
derstood everything at the distances contained in the abscissas, were 
entered as ordinates. 



c Bergmann, Wiesbaden, 1885. 



Hearing-Tests by Whisper. 



73 



1800 



1700 



MO 



WOO 



800 



700 



600 



WO 



300 



100 

50 





B6u.ffl.l6-8 



met. 



met. 



met. 



I do not want to enter into 
a discussion of the high theo- 
retical importance 1 of this 
curve, which is certainly re- 
markable on accouunt of its 760 ° 
regular course. 

The curve ends in an as- jsoo 
cending line which corre- 
sponds to those children who 
hear best. This is due to the 
fact that there was no larger 
space at my disposal than the 130 ° 
gymnasiums which were not 
more than 20 meters in length. 1200 
The curve would have de- 
scended no doubt on the other m 
side in a similarly regular 
way, if the spaces for exami- 
nation had been many times 
larger. The result would 
have been a line similar to 
Gauss's curve of errors. 

The following practical 
rule, the importance of which 
for our hearing tests may eas- 
ily be recognized, can be de- 
duced from this curve; the 
hearing distance of a patient 
must be measured so much 
more carefully, the shorter it 500 
is, since wherever hearing has 
decreased considerably a cen- 
timeter means more to the pa- 
tient than a meter at the limit 
of normal hearing. 

The moistened finger of 
an assistant must be inserted 200 
with considerable pressure 750 
into the depth of the other ear 
in order to surely exclude it. 
One is often in a position to 
convince oneself how incom- 
pletely the occlusion of the Fig. 31. 
Other ear is effected if it is Diagram of the power of hearing for whisper 

in 1918 school children. 

T Schuluntersuchungen, page 20. 



4-2 



2-1 JOO-Jfl 50-25 



mer.jmeUcfn.lcfn., . 



25-12 

cm. 



I2-6 

cm. 



6-3 



3-1 i 1-0 



cm. pfflH 08 



74 Shamming Deafness. 



left to the patient, by the results of examination of cases of one sided deaf- 
ness, which is assured by the objective finding. 

Even a simple hearing test with speech is laborious and takes time 
if it is done accurately, since all the words of numbers from 2 to 9 have 
to be repeated in different double connections so that the patient becomes 
accustomed to the organ of the speaker. 

The distance at zvhich some numbers are heard the least is recorded 
as hearing distance. These numbers are added in parenthesis. 

A room which is not too narrow and about 8 to 10 meters long is suf- 
ficient for practical hearing tests on account of the noise of the day, which 
never can be entirely excluded. It is possible to hear at a much larger 
distance in a narrow corridor. We are justified in considering the hear- 
ing within the limit of the normal whenever all the numbers (the number 
100 included) are heard at this distance (8 to 10 meters). 

Attention was drawn to another point by Oscar Wolf long ago. 
The faulty perception of some letters of high or low pitch alone enables 
us to draw at once diagnostic conclusions as to the probable disease of 
the ear. 

Some mistakes of numbers are met with constantly in all who are 
tested, as soon as we transgress their normal distance of hearing. The 
man who is used to make hearing tests is easily able, from a simple test 
with speech, to detect shamming, on account of this thousand fold expe- 
rience. Numbers are mistaken for others, in the most impossible way, 
contradicting all our experience, and, what is especially committing is the 
great change in the distance of hearing for different numbers, as soon as 
the eyes are excluded. 

The normal ear hears different words, as well as numbers, at a vari- 
able distance, sometimes exceeding by far the distance of 20 to 25 meters, 
which is generally accepted as normal for the perception of a whisper. 

Oscar Wolf 1 ascertained the hearing distance for the sounds of 
speech. 

It seemed to me an indispensable support for the judgment of the 
results of our examinations of hearing, to know accurately not alone the 
distance at which the single sounds of speech are heard by the normal 
ear, but the test words which we use. 

A very large room was necessary for these investigations. I induced 
an army physician, Dr. Morsak, to find the limit of hearing for whispered 
numbers in each ear of 100 young soldiers. The tests were made in an 
absolutely quiet military riding school which offered a space of 89 meters 
in length (289 feet 3 inches). The distances for hearing the whispering 
of simple numbers thus found were as follows : — 



i) „Sprache und Ohr," Brunswig, ed. by Vieweg and son, 1871. 



Hearing Distance for Ntimcrals. 



75 



Aver, of all Mini- Maxi- 

examinations. mum. mum. 
The word "hundert" (pronounce "hoondert") is 

heard at 37.6m. 19m. 81m. 

The word "funf" (pronounce finf) is heard 

at 58.0m. 22m. 89m. 

The word "neun" (pronounce noine) is heard at 59.8m. 23m. 89m. 

The word "drei" (pronounce dry) is heard at 72.3m. 39m. 89m. 

The word "sechs" (pronounce sex) is heard at. . 74.2m. 35m. 89m. 

The word "zwei" (pronounce tzvy) is heard at 75.6m. 40m. 89m. 

The word "acht" (pronounce ackt) is heard at 76.3m. 33m. 89m. 

The word "vier" (pronounce feer) is heard at 77.2m. 40m. 89m. 
The word "sieben" (pronounce seeben) is heard 

at 77-5 m - 39 m - 89m. 




Diagram of the distance of hearing whispered numbers by 200 normal organs of 
hearing, arranged according to the averages for each number. 

Although we had an uncommonly large room of 89 meters or 289 
feet 3 inches in length, 17 meters or 55 feet and 3 inches in width, and 
9 meters or 29 feet and three inches high at our disposal, it was only pos- 
sible to ascertain averages and minima of hearing distances for the normal 
ear. The maximum was reached only for the word 100, as none of those 
tested were able to repeat that word at a larger distance than 81 meters 
or 265 feet 3 inches. All the other words were understood and repeated 
by some through the whole length of the riding school, and would prob- 



76 The Course of the Examination. 

ably have been understood often at considerably larger distances, had a 
suitable room for the examination been at our disposal. This is apparent 
from the fact that some men heard all the whispered numbers from two 
to nine throughout the entire extent of the room (89 meters). It is even 
more evident from the position of the averages between the minimum 
and limit of the room. The averages are all, with the exception of that of 
"hundert," where the opposite is the case, nearer to the limit than to the 
minimum, as is very easily recognized from the diagram in fig. 32. 

The results of these hearing tests of young normal ears seem to me 
nevertheless valuable enough to reproduce them here. The average dis- 
tances of hearing the whisper of words which are the most frequently 
used as test words, are hereby established, and we know especially the 
succession of hearing distances at which the normal ear is able to perceive 
them. 

This puts us in possession of the necessary foundation needed in 
order to judge accurately the great variations which hearing tests in cer- 
tain diseases of the ear show, and which always recur in a similar way. 

The succession of hearing distances for different test words varies 
greatly for different diseases. The deviation from the normal is quite 
characteristic, for example the word "seeben," which is heard at the long- 
est distance by the normal ear, can in some diseases be heard ( only at the 
shortest distance, etc. 

The Course of the Examination. 

Gentlemen : — Before entering into a description of the special pathol- 
ogy of the ear, I want to give you a few points as to how to arrange the 
course of examination so that you do not lose too much time nor miss 
any important details in taking the history, the objective findings, and 
especially the functional tests. 

It is practical in all cases first to take a look at the drum membrane, 
not alone of the diseased but also of the other possibly healthy ear, even 
before entering more carefully into the anamnesis of the disease. 

The visible changes which you find in the external canal, on the drum 
membrane, or, when the latter, and maybe even a part of the walls of the 
meatus are defective, in the drum cavity, will save you a number of 
unnecessary questions, the answers to which are only liable to mislead 
you. 

You must never forget to examine the other, perhaps normally hear- 
ing ear, since, firstly, the statements of the patient as to normal hearing 
are very unreliable, secondly, because the picture of the drum membrane 
of the other side, although there may be normal hearing, gives us a 
chance to compare the ears, and judge accurately small differences of 
color and form in the diseased ear. A number of diseases which have 
run their course long since, may leave traces on the drum membrane, al- 



The Course of the Examination. 77 

though a complete or nearly complete restoration of function has taken 
place, so that often we can read a whole history from the drum mem- 
brane of the ear which is apparently well. 

You will find the drum membrane more or less concealed by ear wax, 
fluid secretions, dried up crusts, masses of epidermis, etc., in about one 
fourth to one fifth of all patients whom you examine. 

It is better to remove carefully such dry masses by the dry method 
than with a syringe, using a probe or a pair of forceps, if beyond the 
obstruction you can see a very small part of the drum membrane. 

The first requirement is of course an accurate knowledge of the 
form of the meatus. The necessary technic can be learned only gradually, 
and requires a very light and steady hand. An injection might, in case 
a perforation of the drum membrane existed, throw collected masses, and 
with them numerous germs of infection and decomposition, into the 
spaces of the middle ear. The light reflexes which we need for our diag- 
nosis change whenever the membrane becomes wet. We are not able 
after an injection to ascertain whether there still exists some abnormal 
secretion in the middle ear or whether it has ceased. Finally the position 
of the masses which gathered in the external canal and their continuation 
into the spaces of the middle ear may be of value for our diagnosis. It is 
for example not at all rare that dry crusts are seen clinging to the upper 
pole of the drum membrane. They must be very carefully loosened with 
a probe and extracted with a forceps, when we will find that they have 
often a continuation far inward, through an opening in the upper pole of 
the membrane, into the aditus ad antrum, and consist of moist white 
masses of cast-off epidermis. A discovery of this kind will direct our 
diagnostic endeavors at once to the right course. 

We cannot dispense with the syringe when there are fluid secretions, 
or when the masses which gathered in the meatus cover up the membrane 
completely, so that there is no free space before it. The removal in the 
latter case has to be accomplished by softening the masses with some 
antiseptic watery solution, and then gradually increasing the force of the 
syringe. The meatus, before it can be examined, must be cleaned with 
cotton wrapped around a probe whenever there are fluid and fetid 
masses. 

I want however to caution you right here to avoid carefully every 
instillation or injection of fluid whenever the history points to the possi- 
bility of traumatic rupture of the drum membrane, or a fracture of the 
temporal bone. 

The appearance of the drum membrane explains whether there are 
inflammatory processes in it or beyond it, or whether there are changes 
of form, which indicate rarefaction of air in the middle ear cavities, and 
coincident disease of the eustachian tubes. It shows whether there are 
fresh or old defects in the drum membrane or in the walls of the meatus, 
which in turn may uncover another succession of changes and defects in 



The Course of the Examination. 



the drum cavity and the adjacent spaces. The drum membrane may 
show scars, or cloudiness, or incrustations with lime salts, or adhesions, 
etc., which put us in a position to draw conclusions as to past suppura- 
tions. We may find, on the other hand, a more or less normal drum mem- 
brane which in itself allows of no further conclusions as to the location 
and pathogensis of the disease of the ear, although the patient complains 
of deafness, otalgia, subjective noises in the ear, etc. 

You can see, gentlemen, from these few intimations, how, after a 
simple inspection of the drum membrane, we can exclude in advance a 
whole series of diseases, and, on the other hand, receive a number of 
suggestions indicating in each case in which direction we must advance 
with our questions and examination. 

By comparing the objective findings with the statements which you 
obtain from the patient and his relatives, you will learn to truly estimate 
the wonderful lack of reliability of those statements. The further course 
of the anamnesis and of the examination will suggest itself, after ascer- 
taining by inspecting the drum membrane, to which of the different larger 
groups of diseases that were just enumerated, a given case belongs, pro- 
vided you are familiar with the special pathology of diseases of the ear. 

Finally I have to remind you again that a complete test of hearing 
with all tuning forks for air and bone conduction which requires so much 
time, is necessary for practical purposes only in a comparatively small 
number of patients. 

Let me shortly repeat what was said before. It is absolutely neces- 
sary in every case to test each ear for whisper, the healthy one as well 
as the diseased. In case whispering is not understood they must be tested 
for conversation. The ear which is not being tested has to be excluded 
as much as possible. 

In all cases where there are objectively visible signs of inflammation 
or destruction of the sound conducting apparatus, no other functional 
tests but for whisper and Weber's test are necessary. An accurate exam- 
ination of the function is however indicated, when the deafness for speech 
is so great that it is out of proportion to the amount of hard hearing which 
we should expect according to our experience from the visible signs of 
inflammation. We must be especially careful and make repeated careful 
examinations of the power of hearing whenever there is a sudden marked 
decrease of hearing in the course of inflammatory or destructive pro- 
cesses. 

Careful tests of the function cannot be dispensed with in any case of 
deafness in one or both ears, in which the finding of the drum membrane 
is altogether negative, or does not completely explain the deafness. This 
is done in the interest of a differential diagnosis of disease of the middle 
or inner ear, or both, which will afterwards govern our therapy. It is 
usually sufficient in such cases to find the upper and lower limit of hear- 
ing for air conduction, the duration of bone conduction for A and a T from 



,The Course of the Examination. 79 

the vertex, Rinne's test for a 1 and perhaps the duration of air conduction 
for a 1 , the middle tone of the whole field of audition. 

We cannot dispense with the test with the whole series of tones in 
those cases of high degree of deafness, where we must expect to find 
and locate gaps in the field of audition or patches of hearing. 

This is furthermore the only means by which we can ascertain total 
deafness in one or both ears. 

The test with the whole series of tones by air conduction is finally 
necessary in all deaf-mutes, in order to discover possible remnants of 
hearing which may be used for instruction by means of the ear. The 
future plan of instruction must be framed accordingly. Hearing tests by 
means of bone conduction give unreliable results in deaf-mutes and may 
be dispensed with for practical purposes. 



SPECIAL PART. 



LECTURE X. 

Diseases of the External Ear. The Auricle and 
Its Surroundings. 

General Considerations. 

Gentlemen: — Diseases of the auricle are observed in but small num- 
bers by otologists. They represent only r.8 per cent of all diseases of the 
ear which I saw from 1869 to 1896, during which time I kept my 
otiatrical statistics. Even the cases of eczema of the auricle which usu- 
ally involve simultaneously also the external canal are included in this 
number. Only 0.6 per cent of diseases which are confined to the auricle 
and its surroundings remain if we deduct eczema. 

Diseases of the auricle occur undoubtedly much oftener but a great 
number of affections of the auricle present themselves only exceptionally 
to the otologist. I need scarcely mention the affections which occur as 
parts of general infections, namely the great number of acute and chronic 
exanthemata which occur in the course of general infectious diseases like 
erysipelas, which so frequently migrates over the auricle, or eczema of 
the face and head, very often implicating the external ear. Those patients 
usually consult the internal clinicist, the paediatrician or the dermatolo- 
gist. The surgeon, on the other hand, sees the injuries and new forma- 
tions of the auricle. 

Notwithstanding these considerable limitations to which the mate- 
rial of observation of the ear surgeon is subjected, the small number of 
diseases of the auricle must surprise one, who considers the position of 
the auricle which exposes it to so many insults, as for instance changes of 
temperature, traumatic and other injuries, which are liable to affect it. 
I never saw for example a frost bite of higher degree. We are therefore 
justified in drawing the conclusion that the auricle, on account of this rel- 
ative immunity against all kinds of damaging influences, has an excep- 
tional power of resistance compared to other parts of the body which may 
be found perhaps in special vasomotor apparatus rendering it much 

80 



Deformities of the External Ear. Eczema. 81 

more indifferent to cold, etc. Its great elasticity and its power of evad- 
ing injuries are furthermore safeguards against traumatisms which 
must not be underestimated. Even injuries like extensive tearing of the 
auricle away from its base heal after simple suturing without leaving any 
deformity whatsoever. There are even a number of reports of cases in 
which auricles completely severed from the head grew on again. 

The diseases of the auricle require here a special consideration only 
in as far as they offer peculiarities compared with other regions of the 
skin, and in as far as they attack also the meatus and the mastoid process. 

Deformities. 

There are mainly three congenital deformities of the auricle which 
are of interest to us : fistula auris congenita, the appendages of the auricle, 
and the rudimentary auricle with atresia of the meatus. This latter deform- 
ity will be considered under the heading of diseases of the meatus, as the 
deformity extends over the meatus, the drum membrane and ossicles. 

The fistula auris congenita is a bag lined with cutis, which lies before 
and above the tragus, where also its opening is found. It may become 
inconvenient to the bearer on account of continual gathering of softened 
masses of epidermis in the canal. These masses often decompose and 
cause abscesses. The excision of the whole bag of skin is indicated in 
such cases. It is accomplished similarly to the excision of a fistula of 
the anus, by inserting a thick probe, under the direction of which the 
excision is done. 

The appendices of the auricle are rudiments of cartilage which lie 
under the cutis most frequently in front of the tragus (compare fig. 42 
page 100). They can easily be removed by excision, whenever they 
form disfiguring protuberances. 

Eczema of the Auricle and Meatus. 

Eczema is by far the most frequent disease of the auricle. Accord- 
ing to my statistics it amounts to two thirds of all diseases of this region. 
One may even say that the auricle is a place of predilection for eczema. 

Eczema is found oftenest in the concha and in the entrance to the 
meatus. The reason for this fact must probably be ascribed to the fre- 
quent irritation of this region by attempts at cleaning with the finger 
and by means of instruments. It develops there also in children in con- 
nection with neglected suppurations of the middle ear. In many cases 
it is a local manifestation of a widespread eczema of the scalp and face. 
It is most obstinate in the fold between the rear surface of the auricle 
and the mastoid process, where rhagades develop which are torn open at 
each harsh attempt at cleaning, thereby rendering healing slow and diffi- 
cult. Eczema at this same place is found not only in children but also 
in women who approach the climacteric years. A frequent starting point 
for eczema is found in the holes for ear-rings in the lobule. 



82 Eczema of the External Ear. 

Eczema of the auricle does not differ in any important particulars 
as to form or course from eczema of other parts of the skin. It is only 
much more obstinate in this place on account of the rhagades which occur 
in the fold behind the auricle, in the concavity of the helix and around 
the entrance of the meatus. They always furnish a new starting point for 
recurrences after the surroundings are healed. Another feature is espe- 
cially harmful : The epidermis of the meatus is constantly saturated with 
secretions which are in putrid decomposition, whenever the cleaning is 
incompletely done in moist eczema of the entrance of the meatus. 

We often see a form of moist eczema in children, which either starts 
acutely by forming little vesicles or by exfoliation of large pieces of epi- 
dermis. A red glossy surface appears, from which, after wiping, little 
drops of fluid well up quickly everywhere (eczema rubrum). The secre- 
tion becomes purulent sooner or later, and adherent crusts are formed 
(eczema impetiginosum). 

We find the different forms or rather stages of the moist eczema 
much more frequently in children of the lower classes, in our free clinics, 
than among better situated people. This may be taken as further proof 
that it is mainly the want of care which is the cause of children's eczema 
and also of its becoming chronic. 

Moist and warm applications must be considered especially favorable 
to the development and maintenance of moist eczema, and every bandage, 
etc., which covers a secreting eczema acts as such. We see vesicles aris- 
ing even on the healthy skin, as the beginning eczema miliare whenever 
moist heat is applied for some time. The maceration of epidermis to- 
gether with the fluid furnish favorable culture media for numerous 
germs. By and. by hypertrophy and thickening of the corium lead to de- 
formities and enlargements of the auricle and even to adhesions at differ- 
ent places, as consequence of the protracted action of all these damaging 
influences. The free margin of the helix along the fossa navicularis is 
most frequently bound down by adhesions, but stenosis and even complete 
occlusion of the entrance of the meatus were formerly often observed as 
consequences of eczema which was neglected for years. The disappear- 
ance during the last decades of equally bad cases, which mostly came 
from the country, points to the fact that there also better care is now 
taken of children. 

Extensive swellings of the lymph glands of the neck may develop 
after long standing eczema of the ear. 

There is one peculiarity of the eczema of the entrance of the meatus ; 
it never extends far into the depth of the canal. The whole epidermis 
of the meatus including that of the drum membrane may become mace- 
rated when the eczema lasts very long, and, in very neglected cases, espe- 
cially when there is at the same time a suppuration of the middle ear. 
the whole lining of the bony canal may be excoriated and the whole sur- 
face covered with a tightly adherent diphtheritic exudation. However 



Eczema of the External Ear. 83 

as soon as we dry out the depth of the meatus and keep it aseptic, the false 
membrane is cast off, the sore spots are covered with epidermis and the 
secretion stops. Little pustules of eczema can never be seen in the bony 
meatus or even on the surface of the drum membrane in acute cases. 

Spontaneous occurrences of moist eczema in the adult is relatively 
much rarer than in children. We find here more frequently forms of 
eczema squamosum, in which scales are formed on the surface of the 
epidermis. They are mostly located at the entrance to the meatus and 
in the concha but are found also behind the auricle, mainly in elderly 
women. Exudation of fluid secretions takes place mostly in the rhagades 
which appear after the disease has lasted very long and improper attempts 
at cleaning were made. 

The eczemata of the ear are just as amenable to treatment as those 
of other parts of the body, if we give due consideration to the local pecu- 
liarities. 

Our main task is above all to locate a starting point of the eczema. 
Ear-rings must of course be prohibited whenever there is a disposition 
to eczema. (In one case I found the ear lobes very much swollen and cov- 
ered with eczematous crusts.- I had to remove by operation little buttons 
of metal which had been screwed in and were completely surrounded 
by new formed tissue.) 

The ear must be carefully examined in every case of eczema to ascer- 
tain whether there is not a perforation of the drum membrane and a sup- 
puration of the middle ear, concealed by masses of epidermis. The re- 
lentless antiseptic treatment of the suppuration of the middle ear in such 
cases, which occur not at all rarely especially in children, is often suffi- 
cient to make the eczema disappear. 

We have to take care in every case, even where there is no suppura- 
tion of the middle ear, that the meatus is dry and aseptic down to the 
curved end of its recessus. This is accomplished by regular daily injec- 
tions with 4 per cent warm boric acid solution, followed by drying out 
with a thin bent probe without a probe-end, wound with cotton, and dust- 
ing of the bony meatus with dry boric acid powder. The injections, which 
are indispensable for the removal of fetid masses of epidermis, are never 
harmful if afterwards the canal is carefully dried out as was just indicated. 

The rhagades at the entrance of the meatus, below the helix and 
behind the auricle must be handled with special care. Every brisk forcing 
apart will tear again the rigid tissue which has become brittle. After the 
crevices are carefully cleaned and dried, they are cauterized with a pure 
or mitigated stick of nitrate of silver, and covered with powder. 

The crusts and scabs on the ear are softened, as in eczema of other 
parts of the body, with non-irritating oils or salves, like unguentum diach- 
ylon (Hebra), zincoxyd salve, borated vaseline, Lassar's paste, etc. The 
crusts, after having been covered over night with the salve, are very 
carefully removed the next morning, and finally the whole eczematous 



84 Secondary Eczema. 



region is covered with a thick layer of powder consisting of equal parts of 
corn starch or oxyde of zinc and boric acid. Lassars paste with or 
without salicylic acid (i to 2%) remains in situ and is renewed twice each 
day till recovery takes place. 

The tar products, like oleum cadini, rusci, fagi, naphthalan, etc., 
ought only to be used in squamous eczema when there are no more excori- 
ated spots and no crevices. They must be very energetically applied till 
all scales are removed from the surface. A camel's hair brush, the hairs 
of which have been cut short and even, is best suited for the purpose. 

The whole surface may be painted with a 4 per cent solution of ni- 
trate of silver after all scales are carefully removed whenever there are 
small secreting spots on the scaling surface. 

The treatments with nitrate of silver as well as the painting with tar 
products may be continued to advantage for a long time. 

A few words may be said about the secondary eczemata. 

Besides the eczemata just described, occurring in connection with 
suppurations of the middle ear, we must consider especially the secon- 
dary eczemata caused by medicines which we use in our treatments. 

Acute eczema may develop on the intact skin and spread over large 
surfaces after the use of iodoform, bichloride of mercury, orthoform and 
even after the mild boric acid. 

A better evidence for the extremely varying individual disposition to 
eczema can hardly be imagined, than this idiosyncrasy of some few people 
against some medicaments which thousands can stand in any quantity 
without the slightest irritation of the skin. The occurrence of eczema in 
such cases can be explained in no other way. Some assistants are abso- 
lutely unable to change a dressing with iodoform and have to be careful 
of every trace of it. They at once, after the slightest touch, develop 
erythema and swelling of the hand and wrist as far as the upper arm, as 
I have seen with my own eyes. 

Of all the eczema due to medicines the eczema due to iodoform is 
that which we see most frequently, on account of the regular use of this 
substance in surgical dressings. It appears absolutely like an acute moist 
eczema with much swelling and redness of the auricle and the other 
parts of the cutis which are covered by the dressing. Numerous mil- 
iary pustules appear on some especially exposed places of the auricle. 
The whole surface which is attacked becomes red and glossy if the iodo- 
form continues to act for some time, and small drops of serum well up 
everywhere. The iodoform eczema has by no means like the genuine ec- 
zema a preference for children; it attacks adults just about as frequently. 
It is usually sufficient to leave out the iodoform gauze and dress with bo- 
rated vaseline in order to effect healing which takes place with the shed- 
ding of the epidermis. 

Orthoform which is such an excellent analgesic I have discarded, 
because in a case of necrosis in the drum cavity causing unbearable pain 



Secondary Eczema. 85 



which regularly disappeared after a dusting with it, it by and by caused 
considerable casting off of epidermis and afterwards a leatherlike shrink- 
ing of the cutis of the whole meatus. Other authors reporting similar 
experiences, induced me to discontinue its use altogether. 

Solutions of bichloride of mercury in dilutions of I to iooo may in 
rare cases cause acute eczema on an intact skin. 

It is finally most extraordinary that violent cases of eczema devel- 
oped even after the use of boric acid powder which otherwise never irri- 
tates. It is true that this occurred in very rare cases only. Round shal- 
low excoriations of the size of a pin's head appear once in awhile (about 
once in 200 or 300 cases), in the cutis of the meatus after boric acid pow- 
der had been insufflated several times. The white epidermis around these 
excoriations is thickened and there is some discharge of serum. There is 
another form which is much rarer still than the foregoing. An acute 
eczema appears w T hich spreads at once over the auricle and its surround- 
ings. There is no question as to effect and cause of this eczema and the 
use of boric acid, for I observed it in the same way on the same individ- 
ual when boric acid was used for a second time years after a first occur- 
rence. In another patient who had an acute suppuration of the middle 
ear, first on one side then on the other, a diffusely secreting eczema of the 
auricle, the cheek and the neck developed a second time in the same way, 
and after boric acid had been used for the same length of time. It only 
disappeared gradually many weeks after treatment with boric acid had 
been discontinued. 



LECTURE XI. 
Othematoma. 

Gentlemen: — There is a disease which is peculiar to the auricle. 
Large circumscribed extravasations of blood are formed which detach 
the pericondrium from the cartilage over a large area. 

I find one case of othematoma to every 2,000 ear patients in my sta- 
tistics. 

The well circumscribed elevation which has the form of a bag, was 
in the cases which I saw, confined to the upper 
half of the anterior side of the auricle. It was 
bluish, flabbily fluctuating and protruding more 
or less convexly. The upper limit of the bag is 
usually the helix, the lower is either the lower 
rid,ge of the fossa intercruralis or it may reach 
farther down into the upper half of the concha 
where the root of the helix forms its limit (com- 
pare fig. 33). 

It was formerly thought that othematoma 
was in connection with diseases of the brain 
because it was often seen in insane asylums. Gud- 
den's researches, however, made it very probable that the origin is re- 
peated traumatisms in the insane as well as in boxers, which is supported 
by the fact that it occurs mainly on the left ear. For prize-fighters it 
was considered so characteristic that the Greeks reproduced it plastically. 
It has become relatively rare in our insane asylums according to personal 
communication from many of our alienists. Othematoma is found more 
frequently in epileptics who are exposed to injuries which can not be 
avoided. 

A preceding trauma was not always established in the anamnesis of 
my cases. The possibility of its formation independently of trauma as a 
consequence of a circumscribed degeneration or abnormal vascularisation 
of the cartilage can not be denied. In the plurality of cases however 
repeated strong traumatisms against the auricle are admitted. 




Fig. 33. 
Othematoma. 



Othematoma, Perichondritis. 87 

The contents, which in the beginning are pure blood, become later on 
a viscid clear fluid. 

Drainage of the fluid by operation, which was recommended, did not 
seem indicated in any of my cases on account of the flabbiness of the bag 
and on account of the lack of inflammation. The therapy which was indi- 
cated by Willi. Meyer consisted in daily paintings with iodine, careful 





Fig. 34. Fig. 35. 

Fig. 34. Othematoma healed spontaneously leaving a deformity of the car- 
tilage. 

Fig. 35. Othematoma on the other ear of the same patient healed under a 

compressive bandage. 

massage and a tight dressing with a pad behind the auricle. The complete 
absorption of the contents takes a rather long time. A lasting deformity 
from shrinkage of the cartilage which otherwise can be seen often, re- 
sulted in no case that we could follow to the end (compare figs. 34 and 35) . 

Perichondritis. 

Elevations of the perichondrium of the auricle by exudations which 
are sometimes like synovia, sometimes like pus, are even more rarely ob- 
served than hematomata. They are located on the anterior surface of the 
auricle like hematomata. The cuticular covering shows pronounced 
symptoms of inflammation, such as heat, redness and irregular thickening, 
which travel slowly over the whole anterior surface of the auricle, with 
the exception of the lobule which has no cartilage. The swelling is pain- 
ful to pressure. Fluctuation cannot be felt everywhere as superficially, 
nor does it reach everywhere to the periphery as in othematoma. 

The course of the disease may extend over several months, during 
which time the cartilage may become partly necrotic. The irregular 
swelling of the soft parts disappears only slowly and leaves more or less 
of a deformity. 

Local tuberculosis of the auricle which is very rare may run its 
course similar to perichondritis. 

The treatment of perichondritis is antiphlogistic. Applications of ice 



88 Erysipelas. 



are used when it begins with the symptoms of a phlegmonous dermatitis. 
The swelling has to be slit open vertically throughout its whole length 
as soon as fluctuation is felt. Necrotic cartilage, if there is any, must be 
removed and granulations curretted. The wound is dusted with iodoform 
powder, and a drain of iodoform gauze is inserted. The auricle is well 
padded in the rear and a dry dressing applied. Deformities and shrink- 
ing of the auricle as final results of perichondritis can not altogether be 
avoided. The occurrence of secondary perichondritis of the auricle under 
the dressing, after total opening of the mastoid process (radical opera- 
tion) and covering of the gap with plastic flaps from the meatus was 
repeatedly reported of late. It caused permanent deformities. Neither 
I nor any of my disciples have ever seen an inflammatory reaction of the 
cartilage or perichondrium after plastic of the meatus. The cause for 
such inflammatory *processes with necrosis, according to my judgment, 
is to be found in the after-treatment, and I believe that moist dressings 
which are strictly proscribed in our clinic are usually responsible for it. 
The effects of a great many bacteria, especially of germs of decomposi- 
tion, bacillus pyocyaneus and others can only be absolutely avoided by 
dry dressings. 

Erysipelas. 

The auricle and its surroundings are often attacked by erysipelas. 
It may start from excoriations and rhagades at the entrance of the meatus, 
or at the auricle. It travels however more frequently over the ear from 
its surroundings. The whole bony meatus and the outer surface of the 
drum membrane become invaded by the disease, whenever it travels over 
the auricle and the entrance to the meatus. This is evident from the 
swelling, and occasionally the subsequent casting off of a bag of epider- 
mis resembling the finger of a glove, which is the lining of the whole 
meatus and drum membrane. A small perforation of the drum membrane 
and an acute suppuration of the middle ear on the afflicted side are not 
infrequent consequences. The course of a suppuration of the middle ear 
after erysipelas is as a rule quick and mild. It does not differ from the 
course of a genuine suppuration of the middle ear, except that in the lat- 
ter the perforation is from the start a little larger. These facts, which 
were gained by careful observation, are especially remarkable because 
they show that the streptococcus (Fehleisen) which is distinguished by 
such a high degree of virulence in the skin; leads very exceptionally to 
cerebral complications when it has a chance to invade the middle ear. I 
saw pyemic symptoms only once in the course of an acute suppuration of 
the middle ear after erysipelas. They disappeared after the mastoid pro- 
cess was opened by operation and the internal jugular vein was ligated. 
The secondary erysipelas which follows wounds of the ear is of special 
importance. It is a general experience that erysipelas, of all infectious 
wound diseases, is the most difficult to exclude from hospitals. I saw a 



Other Affections of the Auricle. 



comparatively small number of cases of erysipelas following- operations 
in our hospital. It was nevertheless evident that even the most careful 
desinfection of the rooms and the objects that were used proved insuffi- 
cient to absolutely check the spreading of the disease to other individuals. 
A safe-guard against such infection of wounds are broad and tight dress- 
ings underneath which the patients cannot enter with their fingers in or- 
der to scratch. We are never absolutely safe from this complication of 
our operations, not even in private practice. Erysipelas occurred in one 
case after I had inserted a lead drainage tube with some force into the 
opening in the mastoid process which had become too narrow. In an- 
other case it developed after an interne, coming from a post-mortem, 
changed a dressing, although he previously had desinfected his hands very 
carefully. Operations and dressings of wounds of the ear are therefore 
to be avoided just as well as work in obstetrics immediately after occupa- 
tion in the post-mortem rooms. 

A granulating surface, when attacked by erysipelas, becomes dark red 
and dry, as though it were varnished. The healing process of the wound 
is perhaps a little protracted, but otherwise not materially interfered with, 
according to my observations. 

I saw only one case terminate fatally from consecutive meningitis 
after a primary erysipelas which started from the ear and progressed over 
the whole scalp. No operation was performed in this case. 

Other Affections of the Auricle and Its Surroundings. 

A number of other affections of the auricle and its closest surround- 
ings must be mentioned. 

Abscesses of the soft parts of the auricle and the entrance to the 
meatus may be primary or secondary, like, for example, abscesses by grav- 
itation from the closest vicinity, as from furuncles in the meatus. They 
usually heal after a simple incision. 

Atheromata, ranging in size from a cherry to a walnut, maybe found 
on the lobule or in the tragus, or on the rear surface of the upper half of 
the auricle. An atheroma should be peeled out together with its entire 
capsule and entrance, a procedure which does not offer any real difficul- 
ties. 

Ulcerations of the auricle may be due to trauma, to frost bite, to 
burning, or to the action of chemicals. They may be caused by dyspa- 
sias, as in scrophulous and atrophic children, or they may be tuberculous 
or luetic ulcers. 

Primary syphilitic affections of the auricle are so rare that Politzer 
could find only three cases in the whole literature. 

The different forms of lupus locate very rarely on the auricle accord- 
ing to my experience. 

Oedema of the auricle and its surroundings may occur after stings 
of insects or after touching the hairs of certain caterpillars. 




90 Other Affections of the Auricle. 

Herpes may affect the auricle and its neighborhood. The eruption of 
herpes over the mastoid process was, in one case, which I observed, pre- 
ceded by a serious neuralgia over the wdiole re- 
gion, which lasted for several months. Paralysis 
of the facial nerve and anesthesia of the acoustic 
nerve were observed in rare cases together with 
herpes of the external ear. 

Arthritic nodules are sometimes found in 
old people along the rim of the helix, having the 
form of a crown of irregularly shaped white 
concretions. 

Fig. 36. One or several slits in the lobule are found 

Angioma. j n t j ie rare CO ng-enital deformity of a double 

lobule. They are much more frequently caused artifically by the weight 
of ear-rings. Keloids of the scar and fibromata of smaller and larger 
size may in rare cases arise from the hole in a pierced ear lobule. Both 
deformities may easily be corrected by operation. Passozv portrayed two 
ugly cases of deformities caused by tuberculosis of the skin which started 
from the piercing of the lobules. Records were published of an ulcus 
durum starting from the same source. 

Telangiectases and erectile tumors of blood vessels may extend to 
the auricle from the neighboring parts, or may be confined exclusively to 
the auricle. The little vascular tumor which is shown in fig. 36 developed 
suddenly during labor pains. It would have been very easy to remove it 
with the galvanocautery snare had the woman returned to the clinic. 

The diseases in the vicinity of the auricle which the otologist sees 
the most frequently are the following : 

Inflammatory diseases of the joint of the lower jazu, the pains of 
which the patient usually locates in the ear. Pressure on the joint while 
opening the mouth increases the pain and sometimes causes the feeling of 
crepitus in the joint. 

Emphysema of the skin behind and above the auricle occurs in very 
rare cases after traumatic or inflammatory rupture of the continuity of 
the outside surface of the bone. 

Parotitis causes considerable swelling below and in front of the ears. 
Perforations of suppurations from the parotid gland into the auditory 
canal are such rare occurrences that I observed only two cases. 

Noma of the Cartilaginous Meatus, the Auricle and Its Surroundings. 

Noma of the ear is such an extremely rare disease that only few 
otologists seem to have seen any cases at all. I have observed two cases 
in the living and made the post-mortem of a third. Nevertheless I want 
to give a description of this dreadful disease which is so very characteris- 
tic. 



Noma of the Ear. 91 



Noma of the ear is a form of gangrene which is in every particular 
identical with the well known noma of the face and genitalia. It does 
not, like the other forms of gangrenous destruction of different parts of 
the auricle, follow after phlegmons, perichondritis, deep ulcers after high 
degrees of frost bites, etc., all of which may lead to partial loss of the 
auricle. It manifests itself as a terminal deep destruction which cannot be 
checked, in very weak anemic and atrophic children in the first few years 
of life. It leads to death within a very few days in all cases that I saw, 
just like noma of other parts of the body. 

Eitelberg 1 described a case which undoubtedly was noma as "dry 
gangrene of the auricle," and collected some few cases from literature 
which may come under this heading. Politzer mentions a case in his 
text book which Hutchinson called noma of the auricle. 

The clinical picture of noma of the auricle according to my own ob- 
servations is about like this : 

The disease seems to attack without exception poorly nourished and 
atrophic children of the lower classes who are not more than a few years 
old and are still under the influence of some serious general infectious dis- 
ease, which is usually measles, but may be typhoid fever, scarlatina, or 
small-pox. It may develop together with chronic catarrh of the bowels, 
scrofulosis and tuberculosis. 

Measles preceded noma in two of my cases, while the third one suf- 
fered from chronic catarrh of the bowels. Symptoms of scrofulosis and 
tuberculosis were present in all of them. Chronic suppurations of the 
middle ear with destruction of the drum membrane were found in all 
three cases. The starting-point for the nomatous destruction was how- 
ever not the middle ear, but in all cases the cartilagcnous meatus, through 
which the fetid secretions passed. 

The case on which a post-mortem was made is the most instructive 
regarding the beginning of the disease and the identity of noma of the 
ear with noma of the face, etc. I had a chance to observe the beginning of 
the disease at the entrance of the meatus. 

The child was 4^4 years old and died of tubercular pleuro-pneu- 
monia. The auricle was intact, but all the soft parts of the region of the 
tongue and chin were destroyed by noma. The cartilaginous meatus, 
with the exception of a small bridge on the top, was separated from the 
bony meatus by extensive gangrenous destruction of the soft parts, which 
spread also between the anterior bony wall of the meatus and the joint of 
the lower jaw, laying bare the whole os tympanicum and the outer sur- 
face of the pars mastoides. The hearth of destruction has the size of a 
quarter, and consists of blackish green shreds of tissue which had a fetid 
smell like carrion and tore like tinder. Pieces of the cartilage of the mea- 
tus, partially denuded and of dirty color, hung from the shreds. 

The drum membrane had two perforations, one in front, the other 



1 Wienermed. Wochenschr, 1885, No. 21. 



92 



Noma of the Ear. 



behind the handle of the mallet, which was still in situ. The mucous mem- 
brane of the drum cavity was not discolored, but yellowish and only 
slightly thickened. The aditus and the antrum were filled with a yel- 
lowish gray pad of mucous membrane which was semi-transparent and 
discharged transparent serum when it was pricked. 

The process on the ear was more progressed in the second case which 
I observed during life : 

It was a very atrophic child of one year and three months, who suf- 
fered from chronic catarrh of the bowels. Both ears discharged since 
birth, the discharge of the right ear being very fetid for some time. 
The auricle of the right ear projected from the head, but did not stand 
at an angle as in subperiostal abscess. The soft parts in front and 
below the ear were swollen, and enlarged glands could be felt. No swell- 
ing or sensitiveness could be found over the mastoid process. Bubbles of 
gas which had a putrid smell were discharged from the meatus upon 
pressure on the swollen parts. There was a large ulcer in place of the 
cartilaginous meatus in which discolored pieces of cartilage floated freely. 
The child had complete paralysis of the facial nerve two days later, 
when the gangrene had progressed over the tragus, transforming it into 
a blackish, dry, shriveled-up crust. A swelling of the size of a walnut 
had formed behind the ear, on the top of which a distinctly circumscribed 

part of the skin was like parchment, 
dried up and blackish. The child 
died a few days later. 

I could watch the process for 
the greatest length of time in the 
third case. 

It was a laborer's child of two 
years and four months who had a 
fetid discharge from the left ear 
1^2 years previous, and measles a 
fortnight previous. It had further- 
more spina ventosa of several pha- 
langes, caries of several vertebrae 
and whooping cough. Paralysis of 
the left facial nerve had existed for 
four days. The ear was raised from 
the head, with a swelling the 
size of a plum over the mastoid 
process, on top of which there was a distinctly circumscribed blackish 
part of the skin about the size of an almond. The whole meatus was 
filled with gangrenous rotten masses which were sharply demarcated 
towards the entrance and consisted partly of free pieces of cartilage. The 
temperature was 103.5 ° F- Three days later the swelling was greenish 




Fig. 37. 
Noma of the ear. 



Noma of the Ear. 



93 






black, sharply outlined from the surrounding healthy skin, and was 7 
centimeters broad and $ l / 2 centimeters high. The lower part of the 
auricle, together with the tragus and antitragus, were now implicated in 
the process (compare fig. 37). A large piece of cartilage was wiped 
out of the meatus. The temperature being normal for the next few days 
and the child having good appetite, I excised the gangrenous masses with 
the consent of the director of the children's hospital, privy counsellor 
v. Rankc. 

The cut was made y 2 
centimeter from the limit 
without narcosis, as no pain 
whatsoever was felt in the 
whole region. Hardly a few 
drops of blood escaped from 
the incision. The cut looked 
like marble and was not dis- 
colored. Black masses which 
tore like tinder had to be left 
around the big blood vessels 
of the neck. The whole os 
tympanicum and the outer 
surface of the mastoid pro- 
cess lay exposed and were not 
discolored after the scurf was 

removed. The process progressed in all directions, incessantly after the 
excision, as shown in a photograph (compare fig. 38), which was taken 
five days after operation. The child died seven days after the operation. 

Noma of the ear is a very characteristic disease and cannot be mis- 
taken for anything else according to the picture which was just given. A 
chronic suppuration had existed for a long time in these children which 
were furthermore much weakened by some serious general disease. The 
gangrene started in each case in the cartilaginous meatus, where deep de- 
struction of the soft parts was found. It probably started from some ex- 
coriation which was exposed to infection from the pus of the middle 
ear constantly flowing over it. The gangrenous process very quickly 
destroys all soft tissues to the tympanic bone, the joint of the jaw, the mas- 
toid process, and causes paralysis of the facial nerve. As soon as the car- 
tilaginous meatus is destroyed the black decomposition appears behind the 
ear, where it spreads excentrically in a few days until death occurs. The 
absolute absence of hemorrhage at the operation in the surroundings which 
were not discolored justifies the supposition that all blood vessels were 
thrombosed to a large distance. 

The tissues which are doomed to necrosis are interwoven with an 
anaerobic form of streptotrix, which forms a thick mycelium of very fine 



Fig. 38. 

The same five days after excision. 



94 Noma of the Ear. 



threads of the fungus in the neighborhood of the rim of demarcation, ac- 
cording to examinations of von Perthes (Arch, fiir klin. Chir. 1899), 
which were confirmed by a number of later investigators. Von Ranke 
found that the mycelium of the fungus grew through the arteries. The 
striking black discoloration of the tissues has to be ascribed to a decom- 
position of the coloring matter of the blood, as the mycelium has no col- 
or whatsoever. The inoculations of the nomatous tissue into different 
animals and of the mycelium which was anaerobically cultivated, have 
given so far no positive results. It is therefore premature to consider the 
fungus the cause of this disease, although it was found in every case in 
which it was looked for according to the method of Perthes. The tis- 
sue which was necrosed for one reason or another may have formed a 
favorable culture medium for its growth. Its regular appearance seems 
however to give the disease its characteristic stamp. 

Wilde speaks in his "Practical Observations about Diseases of the 
Ear" (translation by Haselberg 1855, page 208) about a disease which is 
either closely related to noma, if it is not identical with it, and calls it 
pemphigus gangrenosus. At that time the people called it "the burned 
hole," or "the black ear," "because it often appears on the ears or behind 
them." Wilde says that this disease was so frequent at that time that 
17,799 deaths were ascribed to it within 10 years. In the United States a 
small epidemic of 16 cases of noma after measles was lately described 
(American Journal of medical sciences Nov. 1901 page 587). 

The therapy can only be a surgical one on account of the irresistible 
progress of the destruction. 

A far advanced case of noma of the face was cured in Prague 13 
years ago by extirpation of the cheek and partial resection of the superior 
maxilla. Springer showed it in the meeting of the association of German 
physicians of Nov. 13, 1903. Von Ranke, who has a very large expe- 
rience with noma, saw three cases of noma of the face and one case of 
noma of the genital organs in the children's clinic in Munich, which were 
all cured by extirpation in the early stage, even without great deformity. 
It was on his suggestion that I tried the excision in the above described 
hopeless case, more as a preparation for future cases. 

You can see from our observations that the diagnosis is not difficult, 
even in the beginning when the process of destruction in the ear is con- 
fined to the cartilaginous meatus, which seems to be the regular starting- 
point. The fact that in all our cases the middle ear remained free to the 
end from nomatous changes, must be considered of great practical impor- 
tance. A complete extirpation during the first few days is very possible 
in the ear, yet up to today not a single recovery by operation has been 
recorded. 

The cut has to be made at least one centimeter away from the well 
defined black line of demarcation, parallel with it, according to our ex- 
perience. 



Malignant Neoplasms of the Auricle and of the Meatus. 



95 



The healthy part of the auricle has to be raised with the knife like a 
flap, the upper part of which remains connected with the head (com- 
pare fig. 38). It is used to cover the defect, together with Thiersch's 
skin grafts, which is also done in epithelial carcinoma of this region, as 
we shall soon see. 

Malignant Neoplasms of the Auricle and of the Meatus. 

I saw one case of sarcoma and six cases of epithelial carcinoma of 
the auricle and the meatus, besides malignant tumors which invaded the 
auricle and the meatus from the sur- 
roundings, especially from the paro- 
tid gland. Malignant growths of 
this region are therefore very rare 
occurrences. 

The patient with sarcoma was a 
girl of 9 years. The tumor grew to 
the size of an apple in a few weeks 
and had perforated behind the auricle 
and in front of the tragus, where it 
caused violent hemorrhages. The 
auricle, raised to a considerable dis- 
tance from the skull, was situated on 
top of the tumor completely intact. 

The tragus, the antitragus and a 
part of the concha adhered closely 
to the tumor and had to be removed 
together with it, when it was ex- 
tirpated. After the tumor was peeled away from the os tympanicum and 
pars mastoidea, granulations had to be scraped out of the bony canal and 
the drum cavity before the probe could be inserted into the tube. 

The tumor was histologically an angiosarcoma, consisting of spindle- 
cells with very many blood vessels. It started probably from a molluscum 
at the entrance of the meatus. 

Recovery took place almost without deformity, notwithstanding the 
large defect. The meatus was kept open and a considerable remnant of 
hearing was saved for the girl. 

No recurrence has been noticed up to today which is for three years. 

The epithelial carcinomata of the external ear were confined to the 
auricle, its nearest surroundings and the external canal, with the excep- 
tion of one case which will be described later. The patients were mostly 
women over 50 years of age. The growth of the tumor was always very 
slow extending over many years. No involvement of the neighboring 
glands could be diagnosed. The development of the neoplasm starts us- 
ually from the entrance of the meatus. The surface shows the well- 
known picture of an easily bleeding cancroid with a cauliflower-like sur- 




Fig. 39. 

Cancroid of the external meatus, the 
auricle and its surroundings. 



96 



Carcinoma of the Auricle. 



face, many furrows and a somewhat overlapping rim. Severe pains 
which last for years are always connected with the later course of the 
disease. 

The ulcerating surface may become covered to a large extent by a 
smooth epidermized scar in some cases which are characterized by the 
slowness of their progress. A few places of the periphery only, keep on 
advancing slowly though irresistibly (epithelioma cicatricans). Pain may 
be entirely absent in those cases. The progress of the disease at the pe- 
riphery amounted to only a few millimeters in several years in the case 
which I observed. 

This case concerned a colleague of j6 years. The affection started 
14 years ago after the patient had been stung several times by wasps at 
the outer angle of the eye. The appearance was that of an eczema which 
progressed under the form of separated ulcerating surfaces towards the 
entrance to the ear and behind the auricle. The ulcerations were burned 
many times with the Paquelin cautery. They showed no tendency to heal, 
according to the records of the dermatologist who treated him then, so 
he stopped this treatment. An arterial hemorrhage occurred two years 
ago, after a cauterization with chloride of zinc. It necessitated the liga- 
tion of the temporal artery. All ulcers were nearly healed ij£ years ago 
by treatment with X-ray. They became more extended than ever when 
this treatment was further continued (compare fig. 40). 

When I saw the patient first, two 
years ago, there was an ulcer about 
an inch in diameter at the entrance to 
the meatus and in front of it, with 
steep irregular margins which stopped 
abruptly at the entrance to the meatus, 
leaving the meatus entirely free. 
Around this main ulceration there was 
a large area of scar tissue which was 
surrounded by a large circle of smaller 
ulcers, some of which were raised, 
others flat. The rear surface of the 
auricle and the outer surface of the 
mastoid process were partly ulcerating. 
Fig. 40. The branches of the facial nerve which 

Epithelioma cicatricans of the auricle, supply the forehead and the cheek 
spreading to the eye. were para l yse d. 

The central ulcer diminished to about half its former size with mild 
dressings of boric acid powder and boric acid salve. The patient upon 
my suggestion, treated the ulceration for three months with light and 
eosin. During this period the ulcers again grew considerably larger and 
the region of ulcerations had extended more than a third of an inch all 
around (compare fig. 40). The auricle had become adherent to the 




Carcinoma of the Auricle. 



97 



mastoid process, and under the synechias the ulcers grew larger and 
deeper. It must be added that the patient lately used continual moist and 
warm applications covered with gutta percha. The secretion was pro- 
fuse and very fetid. 

Dry treatment with boric acid powder and boric acid salve, and dry- 
ing out of the meatus caused the peripheral region of the ulcers to be- 
come almost completely covered with skin, and the central ulcer to dimin- 
ish in size. The secretions remained odorless. 

I decided to desist in this case from an excision on account of the 
age of the patient and the pronounced tendency to healing under mild 
dressings. 

This history shows you what a bad effect every active treatment has 
in similar torpid ulcerations. Our main task in every ulceration at the en- 
trance of the meatus is to dry out the meatus down to the drum membrane 
and keep it always and absolutely dry'; besides we must use great caution 
in every change of dressing and carefully clean the whole ulceration. 
This is the only possibility of preventing decomposition over the whole re- 
gion of ulcers, covered by dressings. 

Epithelial carcinoma of the auri- 
cle and the auditory canal was excised 
in two cases after they had both lasted 
for seven years. The tragus, the 
concha, and the antitragus were de- 
stroyed in both cases, while the neo- 
plasm, at least in one case, did not 
invade the middle ear, but remained 
confined to the cartilaginous canal. 
The deformity in both cases after re- 
covery was very small as the defects 
could be very well covered by suturing 
the remnant of the auricle to the head, 
and covering the remainder of the 
wound with Thiersch's skin grafts. 
A wide meatus and good hearing was 
obtained in the first case which was 
operated upon five years ago (compare fi^ 
noticed up to today. 

The tumor in the second case (compare fig. 39) had progressed as 
far as the drum membrane from whose surface growths had to be re- 
moved. A painless recurrence was removed with the sharp spoon a short 
while ago from the bony canal, as far as it could be reached a year after 
the first operation. 

The most important consideration in the prognosis of the epithelial 
carcinoma is the extension of the destruction inwardly. The involve- 
ment of the cheek on the outside and the soft parts behind and below the 

7 




Fig. 41. 
Epithlial carcinoma after operation. 
41). No recurrence was 



98 Carcinoma of the Auricle. 

ear are no contraindications against operative removal, since the defect 
can be completely covered with Thiersch's grafts and by the intact re- 
mainder of the auricle, as was shown in the case we operated last. 

The extension of the disease inwardly is so much more important for 
the prognosis. The condition of the facial nerve and the hearing tests 
give us the most valuable information as to this point. We may without 
hesitation excise the tumor if the function of the facial nerve is intact and 
a remnant of hearing on the involved ear can beyond a doubt be es- 
tablished, even if the new formation has extended ever so far over the 
outer surface. 

The cut must be made in the healthy tissue all around, about J/£ cen- 
timeter away from the limits of the disease. The peripheral part of the 
auricle which was spared by the disease is loosened from below together 
with an upper bridge of the scalp, and turned upwards like a flap, as was 
done in the case in fig. 41. The tumor is then dissected from the bony 
canal and the outside of the mastoid process, when also diseased parts of 
the parotid gland are cut out within the healthy tissue. The bony canal 
and the outside of the drum membrane are scraped clean with the currette 
if the neoplasm extends as far as that. There were no swollen glands in 
our cases, otherwise they must of course be removed. The posterior mar- 
gin of the flap of the auricle is then sutured to the rear rim of the wound 
as far down as possible. The large funnel-shaped defect in front, around 
the bony meatus, is covered with large Thiersch's skin grafts the position 
of which may be secured by sutures all along the periphery. 

The success of this operation is usually favorable beyond expectation 
as to lasting recovery and as to cosmetic effect. The defect is so com- 
pletely masked by the use of the flap of the auricle, that it can not be no- 
ticed except on close inspection, as was the case in the large sarcoma just 
described and also in the two cases of carcinoma. 



LECTURE XII. 
Diseases of the External Meatus. 

Gentlemen : — The diseases of the external ear amount to 22 to 23 per 
cent of all diseases of the ear according to my statistical compilations. 
In this number are included the diseases of the auricle which., as we saw, 
are relatively rare, and the independent disease of the drum membrane, 
which occur only sporadically. 

This number diminished some during the later years in my statistics, 
as in those of other authors. The cause of this fact must be found in the 
greater accuracy of our diagnosis, by which the number of cases of otitis 
externa diffusa especially was reduced. There is no doubt but what form- 
erly a number of cases of suppurations of the middle ear were wrongly 
diagnosed as diseases of the external ear, because their secretions found an 
avenue of escape to the outside, either through a very small opening in the 
drum membrane, or in the wall of the canal, which we could not see at our 
examination. YVe shall enter into further particulars in speaking about 
otitis externa diffusa. 

Congenital Atresia of the Meatus, together with 
Rudimentary Auricle. 

This arrest of development must be dated back to an early period of 
embryonal life and comprises besides the meatus also the auricle and the 
chain of ossicles. We had better speak about it here, as in every case the 
meatus and the drum membrane are totally absent, while the auricle, the 
hammer and the anvil are present, though rudimentary only. 

The occurrence of congenital atresia of the auditory meatus is rela- 
tively frequent. There is one case in about every 2,000 ear patients ac- 
cording to my experience. It is not very rarely found on both ears (once 
in about every six cases). 

A small irregularly formed rudiment of cartilage which is covered 
with skin is seen on the outside in place of the auricle. It has no entrance 
to the meatus (compare fig. 42). The mastoid process starts directly 
behind the glenoid process of the lower jaw. I can best show you the 
great anatomical deviations from the normal by means of a case on which 
I made a post-mortem (compare fig. 43-44). 

You see the glenoid process of the lower jaw together with parts of 

99 

t.orc 



100 Congenital Atresia of the Meatus, and Rudimentary Auricle. 



the parotid gland dissected forward from the outside of the temporal 
bone and from the mastoid process. The fossa mastoidea continues for- 
ward into the root of the zygomatic 
process without being interrupted 
by the aperture of the meatus. 

There is a cut through the 
drum cavity and tube (compare 
fig. 44). On the upper half of the 
cut in place of the drum membrane, 
you see the bony lateral wall of the 
drum cavity together with the rudi- 
ments of the two first ossicles. 
There is only the head of the ham- 
mer present with the tendon of 
the tensor tympani muscle, also the 
anvil, the long process of which 
terminates in a short hook-like 
point. The normally developed 
medial wall of the drum cavity appears on the other half of the cut 
with the promotory, the nitch of the round window and the stirrup 
with its tendon. 




Fig. 42. 

Atresia of the external meatus and 
rudimentary auricle. Anterior of the 
latter are cartilaginous appendages. 




Fossa mast, 
(no meatus) 



Strands of con- 
nective tissue and 

facial nerve 
emerging from the 

for. stylomast. 



s 

Parotis. Cut through the glenoid proces of the lower jaw. 

Fig. 43. 
External surface of the temporal bone. 

A compilation from literature which I induced Joel to make, of all 
cases of which a post-mortem had been made, established the fact that 
there was a complete aplasia of the os tympanicum and consequently also 
of the drum membrane, just the same as in my case. The labyrinth and 
its windows together with the stirrup were nearly always found intact. 
The latter was often less movable than normal. 



Congenital Atresia of the Meatus and Rudimentary Auricle. 101 

There is therefore usually a considerable remnant of hearing con- 
nected with this deformity. Deafness (of course only for air conduction) 
is present only for the lower half of the normally audible sound scale, up 
to the one-stroked octave. The higher we ascend the scale from there, the 
better becomes the perception of the sounds. Hearing by bone conduc- 
tion is considerably improved, as in all affections of the sound conducting 
apparatus. 

Children are able to learn how to speak even when both ears are 
thus deformed. Consequently we do not find these children in deaf-mute 
institutions, but in public schools. 



Malleus Incus 



Tendon of the tensor tymp M. 



Tuba 



Art. 
carot. int. 




Fig. 44. 
Section through the tube, drum-cavity and antrum mast. 

Surgeons and otologists have tried repeatedly by operation to uncover 
a meatus, leading into the depth. This of course proved futile in every 
case on account of the nature of this anomaly. 

Scheibe however tried a new operation in a case where both ears 
were deformed, the functions of which I had previously tested. It re- 
sulted in a considerable improvement of hearing. The antrum mastoid- 
eum is generally well developed and communicates with the drum cavity, 
as in our case of which pictures are given in fig. 42-43. Scheibe there- 
fore opened the antrum from outside, forming a wide canal which he 



102 Exostoses and Hyperostoses of the Meatus. 

lined with Thiersch's skin grafts. The hearing distance improved from 
10 centimeters to 18 centimeters as a consequence of this operation, and 
the power of hearing tested with the continuous series of sounds extended 
two more octaves downward by air conduction. 

The Eustachian tube was several times found abnormally wide in 
cases of atresia of the auditory canal. Considering this fact, it would be 
worth while trying whether or not a hearing-tube, which is introduced 
through the nose, might improve hearing of speech in some cases. 

Exostoses and Hyperostoses of the Auditory Meatus. 

The exostoses in the bony meatus which Virchow found in many 
Mexican skulls and which he explained as a peculiarity of the race, must 
be considered as congenital deformities. 

Their occurrence at the present time and also in Germany is not at 
all rare. I found them in 0.6 to 1 per cent of all ear patients whom I saw. 

Koerner in Rostock found them in 3.8 per cent of his patients, and 
says that they are even more frequent in Great Britain. 

We call exostoses small round bony growths which are usually found 
as little white circumscribed elevations in groups of two or more on both 
sutures of the deepest part of the os tympanicum to the horizontal part of 
the scale of the temporal bone. One protuberance is usually directly in 
front, another close behind the short process of the hammer in the drum 
membrane. A third one often protrudes between the two. 

Hyperostoses present themselves more in the form of diffuse bulgings 
of the anterior lower, and sometimes also posterior lower wall. A cross- 
cut through the meatus has consequently the shape of a pear with the point 
downward. 

We shall speak about exostoses and hyperostoses together, as they 
are found not infrequently in the same ear. There are many peculiar 
points as to their occurrence. This anomaly is often found in several 
members of the same family. There is no proof of a special diathesis 
for this disease as lues, arthritis, etc. They develop nearly always after 
puberty. In 170 cases which I observed up to 1896 there was none below 
15 years. Neither did I find a single case in public schools or deaf-mute 
institutions. 

They occur oftener in both ears than only in one. At times their de- 
velopment on the second ear can be observed later on. 

The male sex is affected much more frequently than the female. My 
statistics show a proportion of 11 to 1, those of Koerner of 3.5 to 1. 

Finally I was able to prove that exostoses are an affection of the well 
to do classes, and are almost never found in poor people. This point was 
also confirmed by the statistics of Koerner. 

Continual awkward attempts at cleaning the ear with all kinds of in- 
struments on the part of the patient seem often to cause a more rapid 
growth. -. 



Acquired Atresia of the Auditory Canal. 103 



A complete occlusion of the meatus occurs only very exceptionally as 
a consequence of their enlargement, since even though they may touch 
each other, they leave an aperture with many corners. There is no se- 
rious interference with the function, except when this aperture is closed by 
ear-wax or epidermis which was pushed into the depth. Otherwise it 
is a fact established by experience that the narrowest aperture is sufficient 
for a nearly normal hearing. 

The patients must therefore be prohibited from pouring water into 
the auditory canal or from diving into the water. 

The removal of the swollen epidermis, etc., from between the exos- 
toses and the drum membrane is often very difficult. It is accomplished 
with a straight antrum tube (compare fig. 66). 

Removal of the exostoses by operation becomes necessary only ex- 
ceptionally. It is indicated when one ball-shaped exostosis closes up the 
meatus completely. It may become imperative whenever secretions have 
gathered between the exostosis and the drum membrane, or when there 
are decomposed masses of epidermis or pus in cases where there is at the 
same time a perforative inflammation of the middle ear. 

The auricle must be detached in the rear in order to remove a ball- 
shaped exostosis of the meatus which fills the aperture of the canal. The 
rear circumference of the meatus is cut at the line between the cartilag- 
inous and bony meatus. This is done for two reasons. The first is that 
we may use our chisel as sparingly as possible along the rear and upper 
wall of the meatus, which is concave downward. The second is that a 
large exostosis can not be delivered through the isthmus which the carti- 
laginous meatus forms. 

Small and multiple exostoses never need be removed by operation. 

Acquired Atresia of the Auditory Canal. 

The meatus may become closed from ulcerations of the soft parts 
in which the bone may or may not participate. 

An occlusion in the deeper part of the meatus may be formed by con- 
nective tissue or by bone and will occur after serious suppurations of the 
middle ear. with removal of sequestra. Very rarely only a bridge may 
form. 

Ulcerations on the entrance of the meatus may lead to occlusion by 
scars, as I once saw in a case of badly neglected eczema in a child. 

Occlusion of the meatus was observed repeatedly after serious inju- 
ries caused by machines, tearing away the soft parts from the vertex down- 
ward in the shape of a large flap, which included the auricle together with 
the cartilaginous meatus. This flap is very difficult to readapt, and dur- 
ing recovery often moves more or less downward, so that afterwards the 
aperture of the torn piece is not congruent with the rest of the aperture of 
the canal. The dislocation is easily shown by the different height of the 
two auricles. 



104 Foreign Bodies in the Meatus. 

The insertion of a rubber drainage tube into the meatus down to its 
bony part, in order to avoid later occlusions, must never be neglected dur- 
ing the process of recovery after similar injuries which have severed the 
aperture of the meatus entirely or in part. 

The suppuration, in occlusion of the meatus after the removal of a 
sequestrum, has generally stopped in the depth long before the seques- 
trum is expelled. The power of hearing is entirely lost in the greatest 
number of cases. (The whole labyrinth was removed as a sequestrum in 
a case which I observed.) There is therefore no reason to reopen the 
depth by operation. The reopening by radical operation will however be 
necessary when there are symptoms of continuation of the suppuration 
inside of the occlusion. 

Consideration of hearing can only become an indication for opera- 
tion for the reopening of the aperture in occlusions which are very far 
outward, and when the functional tests with tuning forks show sufficient 
hearing in the diseased ear (see the hearing tests in congenital atresia of 
the meatus, page 101). 

A cross-shaped incision is sufficient when the scar is not too thick. 
You must not forget that an aperture can only be found in the upper 
part of the scar in occlusion of the canal after dislocation of the flap in 
injuries by machines. The cross incision may be enlarged by insertion of 
a stick of laminaria, which must remain there for a few hours only, on ac- 
count of its rapid and considerable enlargement. It is sufficient when in 
this way an aperture is created large enough to insert a solid cylinder- 
shaped pledget of cotton, which is made by wrapping some cotton tightly 
around a thin probe without a probe end, slipping it off and dipping it 
into iodoform powder. 

The aperture on the inside of the occlusion will be found completely 
filled with a pulp of cast-off epidermis and little hairs whenever the occlu- 
sion has lasted long enough. In one such case I found a large dry per- 
foration of the drum membrane behind the occlusion, which existed since 
before the injury. 

A small permanent opening which never closes entirely is sufficient for 
the improvement of the power of hearing. Chiseling away of the rear 
wall of the meatus and large plastic operation of the meatus, by the for- 
mation of flaps in order to create a large aperture, becomes necessary 
only exceptionally. 

Foreign Bodies in the Meatus. 

The removal of foreign bodies from the external meatus is a very 
frequent cause for treatment by a physician. One case of foreign body in 
the ear is counted to every 60 to 70 ear patients according to my statis- 
tics, in which number the number of cases of plugs of ear wax was left 
out of calculation. 

The permanent lodging of a foreign body in the auditory meatus is 



Foreign Bodies in the Auditory Canal. 105 

in itself perfectly innocuous. It neither interferes seriously with hearing 
nor does it cause any other disturbance (the serious reflex neuroses which 
in earlier times were repeatedly recorded seem to have been wrongfully 
ascribed to the ear, as nobody has seen them of late). The consequences 
of awkward attempts at extraction, on the part of laymen and physicians, 
have become fateful for a great number of patients and physicians, as not 
a few patients have died and will die from this cause. There is hardly 
another domain in medical science where blind operative zeal without 
sufficient knowledge of anatomy and technic can cause so much damage. 

Living animals find their way not very rarely into the ear, where they 
cause violent pain by their movements in the bony canal and on the drum 
membrane. Flying insects, parasites of the house, especially Blatta ori- 
entalis, (bed-bugs) are not infrequently found. I once removed even a 
small snail together with its shell which stuck tightly to the drum mem- 
brane. The strong jet of a syringe is sufficient without exception for 
their removal. You may find mentioned in all text books that larvae of 
flies were found developing in the bony meatus and the open spaces of the 
drum cavity in fetid otorrhoea. No modern author has ever reported such 
an occurrence, nor did I ever observe it. It is therefore permissible to ex- 
press a doubt as to the accuracy of the observation, especially as decep- 
tions caused by quick changes of reflexes of light in the depth of the canal 
may occur so easily. 

The great variety of foreign bodies like seeds of different fruits, 
kernels, stones, pebbles, glass beads, catkins, etc., which children put into 
their own or each other's ears are much more important to us. They can 
easily be removed with the syringe as long as they do not go beyond the 
place where the finger of the child is able to push them. As a rule they 
do not advance any further into the depth than the cartilaginous meatus. 

The removal of a foreign body which has slipped into the bony mea- 
tus can be facilitated by pouring some oil into the ear which makes the 
walls more slippery. The syringing in this case has to be done with the 
patient lying on his back, his head overhanging, and the auricle pulled 
back sufficiently to straighten the meatus. The canula of the syringe 
must not fill out the entrance of the canal. In this position the posterior 
and upper wall of the meatus become the lower wall, and, together with 
the drum membrane, forms a continuous inclined plane over which the 
foreign body can slide out. The foreign bodies in children are generally 
round, so that the jet of the syringe rolls them out easily. 

Syringing must be avoided when the foreign body has a concavity 
facing outward, so that the jet may be caught in it, as happens in little 
bone buttons of a lead pencil, so often found in the meatus. The re- 
moval of that kind of foreign bodies is easily accomplished with a very 
slender knee-shaped bent forceps. Spikate blossoms (catkins, etc.,) also 
are difficult to remove with the syringe and are more easily dislodged by 
a dull curette used like a lever, under the control of the speculum. 



10G Foreign Bodies in the Auditory Meatus. 

Some kernels swell when they become wet, like peas, beans, stones of 
the locust bean. This may occur when the walls of the canal were injured 
by means of instruments in previous attempts at removal, or if water en- 
tered into the canal. The foreign body, when it is soaked, fills out the 
aperture of the canal completely. The outside of such highy enlarged 
and partly softened kernels is often found scratched by instruments, and 
cannot be attacked from the walls of the meatus. Their center was for- 
merely burned with the galvanocautery and in this way reduced. This 
method was justly discarded because serious reaction of the surroundings 
was often observed. 

The removal with instruments is indicated also when there is a per- 
foration of the drum membrane, as in that case the jet of the syringe loses 
its power. 

Adults evade incompetent interference very soon, while children us- 
ually have to undergo a number of more or less awkward attempts at re- 
moval before they are brought to the otologist. 

Remembering the form of the meatus as I described it to you (page 
36), you will understand how easily a foreign body by means of in- 
struments may be pushed over the isthmus at the inner end of the carti- 
laginous meatus, whence it falls into the much wider bony part, from 
where, if pushed further, it glides along the smooth inclining walls to the 
drum membrane. Now it is a matter of good luck. If the foreign body 
is too large to pass the aperture of the deeper part of the bony canal 
which again becomes narrower at its end, it becomes wedged in at this 
place, if persecuted by further energetical attempts at removal. If how- 
ever it is small enough, it will be pushed into the drum cavity through the 
drum membrane which tears very easily. 

I will cite only one example. A hollow glass bead had to be re- 
moved from the drum cavity in many small fragments. It arrived there 
in the manner just described and was then broken to pieces. 

The set of instruments for the removal of foreign bodies, which are 
wedged in the depth of the meatus or were pushed through the torn drum 
membrane into the middle ear, consists of spoons, of a number of knee- 
shaped bent, very slender forceps with different curves, small dull, single 
and double hooks, sharp ones for soaked kernels, beans, peas, etc. The 
steel of the shank of these instruments is handled in such a manner in 
hardening, that the shank allows of bending (Brethold). You will see 
in fig. 45 a set of these instruments together with the very practical han- 
dle of Burckhardt-Merian, also the instruments for paracentesis, for ex- 
traction of the hammer, tenotomy of the tensor tympani muscle, etc. 

A deep narcosis can never be dispensed with in removing foreign 
bodies from the auditory meatus of children. 

Surgeons often did not stop in the drum cavity in their search for 
foreign bodies. We find the foreign body, if it is pushed still further, 
either wedged in the end of the bony part of the Eustachian tube or in the 



Foreign Bodies in the Auditory Meatus. 107 

aditus ad antrum. The luxation of the stirrup is the greatest danger in 
all these manipulations, according to my experience. The suppuration of 
the middle ear which can not be avoided in such a case, will invade the 
labyrinth and from there the meninges. This is the explanation for a large 
number of deaths which occurred after forced attempts at extraction of 
foreign bodies. At the post-mortem of a case which I published in the 
Berl. klin. Wochenschr. 1880 No. 26, I found a seed of the locust bean 
which had been pushed into the tube where it was wedged in tightly and 
became the cause of death. 

We do not succeed in removing a foreign body through the meatus, 
when it is pushed that far. The bony canal joins the bony Eustachian tube 
in a curve (compare fig. 5 page 9). We ought therefore to be able 
to insert our instruments in a direction from upwards and backwards. 
The detachment of the auricle from the rear for this purpose is an opera- 
Double hook. 
Dull hook. 
Denticulated curette. 




Smooth curette. 
Knife for paracentesis with handle according to Burckhardt-Merian. 




Fig. 45. 

tion which was done long ago by Paulus of Aegina. We can get a very 
wide and straight avenue of access to the tube, especially in children, if 
we detach the posterior and upper circumference of the cartilaginous 
meatus from its attachment to the bony meatus. There were two in- 
stances for example only during the last year, where some' doctors had 
pushed catkins into the tubes of two children. I removed them in the 
above described manner by means of slender forceps. 

The detachment of the auricle however is not sufficient after the for- 
eign body has entered into the aditus ad antrum. In this case, as in rad- 
ical operation, we have to chisel away the whole posterior wall of the bony 
meatus. 

Thus a cast of plaster of Paris which filled out the whole meatus 
had to be removed in this manner. It had been made unintentionally in 
the psychiatric part of the hospital while preparing a cast of the auricle, 



108 Fractures of the Auditory Meatus. 

but the meatus not being sufficiently closed with cotton, the plaster filled 
it out entirely and there became hardened. 

The atrocity of filling both ears of an intoxicated man with molten 
lead occurred some time ago. Such a cast is absolutely immovable in 
the meatus. I became convinced from experiments on a cadaver that the 
weight of the whole body may be lifted up by the part of the cast which 
fills out the concavity of the auricle without pulling the cast out of the 
meatus. The rear wall of the bony meatus must be chiseled away in 
such a case in order to remove the cast. 

Plugs of cotton glided into the depth of the ear must finally be men- 
tioned among the foreign bodies of the ear. They are not at all irrelevant 
in the cases where there is a perforation of the drum membrane, because, 
as foreign bodies, they cause and increase suppurations and decomposi- 
tions. One sometimes sees fetid suppurations of the middle ear, even with 
serious cerebral symptoms disappear as if by magic, after removal 
of a plug of cotton or a piece of gauze, which found its way into 
the middle ear. I repeatedly saw such plugs of cotton like other abused 
foreign bodies surrounded by granulations. In one case I found several 
plugs pushed so tightly over the free margo tympanicus into the aditus 
ad antrum that they could be removed only by means of a forceps and 
strong traction. 

Fractures of the Auditory Meatus. 

Fractures of the auditory meatus are either continuations of fractures 
of the base of the skull, when as a rule also a rupture of the drum mem- 
brane is found, or they may be a part of injuries caused by a shot, or 
finally they may occur as a result of indirect force which acts on the 
lower jaw, and, through its glenoid process, on the auditory canal. The 
most frequent cause is a fall forward from a horse, or a horse's kick 
on the chin. They are confined to the anterior bony wall of the meatus 
and are either simple fissures or comminuted fractures. A rupture of the 
drum membrane is the exception, if this is the cause of the fracture. 

The anterior wall of the meatus is formed, as you know, by a thin 
lamella of compact bone which has a larger or smaller physiological 
gap of ossification during the first few years of life. There is generally 
a hemorrhage from the ear, because the thin and tightly adherent lining 
of the bony canal tears. A small piece of bone sometimes becomes mov- 
able as on a hinge. One can later on recognize the line where a fissure 
took place from the terrace-shaped incline. I saw in a child six weeks 
after it received a kick on the chin from a horse's hoof, a growth which 
filled the whole depth of the meatus, after the removal of which, the 
drum membrane and the hearing distance were normal. 

The therapy of fractures of the external meatus consists first in wip- 
ing away fresh blood clots with some cotton wrapped around a probe. 
The meatus is dusted with boric acid powder and closed with iodoform 



Ear Wax and Masses of Epidermis in the Meatus. 109 

gauze. Syringing and instillations of fluids must be strictly prohibited. 
In complicated fractures of the meatus the lower jaw must be immobil- 
ized. 

Obturation of the Meatus by Gathering of Ear Wax and 
Masses of Epidermis. 

The occlusion of the auditory canal by ear wax, dust and cast-off epi- 
dermis belongs to the most frequent causes of deafness. In nearly 13 
per cent of all ear patients whom I have seen, the disturbances of the 
function of hearing were caused in this simple manner. 

Plugs of ear wax which close up the canal entirely are exceptions 
in children. Old people with flabby, slit-shaped entrances to the meatus 
are frequently affected. Complete hard casts of the bony meatus are 
found at this age. They may protrude into the cartilaginous meatus and 
interfere with hearing to such an extent that the patients are absolutely 
deaf for speech, especially when at the same time a certain amount of 
deafness due to old age is present. 

The secretion of cerumen takes place in the cartilaginous meatus 
only, as far as there are ceruminal glands. It there forms a safeguard 
against the entrance of all kinds of damaging influences like the hairs 
in the meatus. The secretion is completely w r anting in many people with- 
out any recognizable damage to the integrity of the ear. 

The ear wax reaches the depth of the meatus only by unsuitable 
attempts at cleaning, by instillations of water, manipulations with the 
corner of a towel, instruments, etc. Otherwise it can not get further than 
the cartilaginous meatus nor gather in the depth. 

Obturating masses of epidermis however may develop in the bony 
meatus where they may be found in two modifications. 

Sometimes, what appeared to be a plug of ear wax syringed out of 
an elderly person's ear, can be unraveled into long ribbons of epidermis 
with fine crosswise folds. These peculiar ribbons, which I described 
years ago, lie in the bony canal rolled up like a snail, and their end is 
often attached to the innermost part of the upper wall of the canal. The 
most wonderful part of these ribbons is their length, which amounts often 
to many times that of the whole meatus. We draw the conclusions from 
this peculiarity of the ribbons that the physiological production of the 
epidermis is a process of migration of the hornified layers which pro- 
gresses slowly from the inside outward. The largest production takes 
place in the region of the posterior upper wall of the meatus. We can 
study the same process in the gradual migration of extravasations of 
blood, or of dried up crusts of secretion, which, often starting from a 
small secreting spot of the drum membrane, may form regular ribbons 
which extend into the cartilaginous part of the meatus. 

There is another much rarer form of gatherings of epidermis in the 
meatus. They are thick, white shells which are arranged in concentrical 
layers or irregularly crushed convolutions without any considerable 



110 Ear Wax and Masses of Epidermis in the Meatus. 

amount of cerumen admixt with it. They may fill the whole bony meatus. 
The usually concentrical arrangement of these shells as compared with 
the rolled up ribbons, points to the fact that there must be some disturb- 
ance of the physiological growth of the lining of the meatus, because the 
most frequent and therefore physiological process of growth of the lin- 
ing is the one which was first described. It is by gradual migration and 
casting off of the hornified epidermis outward, by which automatic clean- 
ing of the surface of the drum membrane and bony meatus is effected. 
We often after the removal of these concentrical shells of cast off epider- 
mis find a number of other changes, like excentric enlargement of the bony 
meatus, very pronounced cloudiness, anomalies of form of the drum mem- 
brane, sometimes with adhesions to the inner wall of the drum cavity. 
It must be considered highly probable that this abnormal production of 
epidermis emanates from old defects of the drum membrane which have 
healed by formation of scars. Pieces of the inner wall of the drum cav- 
ity which are also epidermized may have grown into these scars. The 
whole process was justly compared by some authors to the cholestea- 
toma of the middle ear. The center of these shell-like formations may by 
and by become decomposed to a putrid cheesy mass, the same condition 
that we observe in cholesteatoma of the middle ear. 

The removal of plugs of cerumen and masses of epidermis is best 
started by instillations of some warm solution. We never know in advance 
whether the spaces of the middle ear are not layed open, in which case 
the entrance of water with germs of infection might cause suppuration. 
We use therefore a saturated warm solution of boric acid. The patient 
is instructed to let somebody fill his canal several times with the solution, 
and leave it there each time for 10 minutes. It is best for him to lie down 
on the side of the good ear and have the nurse pull back his auricle ener- 
getically (in order to enlarge the slit-shaped entrance). The patient in 
order to avoid unnecessary excitement must be warned that his deafness 
may increase considerably through enlargement of the plug when it be- 
comes soaked, if there is a small space between the plug and the wall. 
A moderately strong jet of the syringe is generally sufficient to remove 
the masses after they have been soaked for one or two days. The 
canula of the syringe is pressed against the rear upper wall of the carti- 
laginous meatus and the jet is directed perpendicularly to the lateral plane 
of the face corresponding to the axis of the meatus. The removal of the 
concentrical masses of epidermis is sometimes more difficult, because their 
peripheral layers adhere tightly to their base. They must be made acces- 
sible to the jet of the syringe by repeated soakings with warm I to 2 per 
cent solutions of soda in water or salicylic acid in alcohol. The syringe 
must often be supported by the probe and forceps. 

The meatus, after the drum membrane has become entirely clear, 
is carefully dried out down to the recessus meatus with a bent probe 
wrapped with cotton. An examination of the function of hearing is made 
and the canal is closed with a piece of dry cotton for one day. 



LECTURE XIII. 

Circumscribed Diseases of the External Meatus. 
Otitis Externa Circumscripta (Furuncles, Abscesses). 

Gentlemen : — The external meatus is the seat of predilection for 
furuncles, on account of the great number of glands and hairs, and still 
more on account of the many manipulations to which it is exposed. 

In my statistics 3.3 per cent of all ear patients suffered from it. 
89.3 per cent of them were adults, 10.7 per cent children. 

The female sex is attacked by furunculosis oftener than male, con- 
trary to what we notice in other inflammatory affections of the meatus. 

I became convinced from many years' experience that furuncles devel- 
op exclusively in the external region of the meatus which carries the hairs. 
A number of other authors came to the same conclusion which, as we 
know, coincides with the pathogenesis of furuncles established by experi- 
ments. Manipulations on the part of the patients with their finger-nails 
instruments, etc., are as a rule the direct cause for their beginning. 

Severe spontaneous pain and especially pain on pressure on the 
tragus and auricle is felt at the place of development of a furuncle some- 
time before the appearance of a slightly red local swelling. A collateral 
oedema often forms in a large area surrounding the ear during the de- 
velopment of big furuncles. Some glands in the fossa retromaxillaris 
may become enlarged and may be very sensitive to pressure. The oedema 
which shows on the mastoid process may be mistaken for a symptom of 
inflammatory disease in the bone, as long as the furuncle is not accurately 
localized. The great sensitiveness to pressure on the tragus and especially 
on the meatus from below indicates the starting point of the pain. Hear- 
ing which we find to be nearly normal when tested with a small ear funnel 
inserted into the canal in order to spread the slit between the swollen walls, 
excludes a disease of the middle ear. 

Small furuncles may be absorbed without being opened. A pustula 
forms as a rule on the top of the furuncle, from which sometimes a 
comparatively large plug of pus is expelled. Microscopical examination 

111 



112 Otitis Externa Circumscripta. 

shows that these plugs contain fresh leucocytes, conglomerations of more 
or less degenerated cells, masses or bacteria, hairs, here and there some 
ducts and tubules of glands, finally fibrin which surrounds the plug in 
dense strands and of which fine strands perforate it. 

Sometimes several furuncles arise at the entrance of the meatus 
simultaneously or one soon after the other. Furunculosis was observed 
in 6 per cent of all cases in both ears at the same time. 

A large amount of -fibrinous exudation and growths of granulation 
may form on the surface of the pustule, if it is permitted to be constantly 
bathed in pus. 

A flat spherical fluctuating abscess of considerable size may in rare 
cases develop at the entrance of the meatus. 

Abscesses by gravitation emanating from furuncles of the meatus in 
some rare cases may appear below and also in front of the ear. The fluid 
discharges through the opening of the furuncle into the meatus if such 
abscesses are incised and rinsed out. 

The incision of a furuncle, which is done with a sickle-shaped knife — 
is necessary very exceptionally only, since usually slight pressure with the 
ear funnel is sufficient to remove the semi-solid plug. The incision of a 
furuncle is very painful, and fainting of the patient is not rare. It is 
sustained more easily when a large abscess has formed. 

The whole course of furuncles has become much more painless, since 
we avoid moist heat in treating them, nor do we see many recurrences. 
The formation of fibrinous exudations in the aperture of the meatus, the 
luxuriant growths of granulations, and the formation of abscesses by 
gravitation have not been observed since we avoided this form of treat- 
ment. 

The treatment we have been using regularly for many years consists 
in the insertion of cylindrical plugs of very absorbent cotton (out of 
which the oil is completely extracted). These tampons are made by twist- 
ing the cotton tightly around a probe, dipping them into iodoform pow- 
der. They have to be renewed every day before and after incision of the 
furuncle. 

The slight permanent compression seems to have a favorable effect 
on the pain. A few doses of morphine of one centigram each may some- 
times become necessary during the first few days. 

The principal advantage of this method of treatment seems to me 
to be the withholding of fluids in which, especially when moist heat is ap- 
plied, exuberant development and new growth of bacteria in different 
spots takes place. The bacillus pyocyaneus for example has not been 
observed since we use these dry tampons. 

The formation of secondary furuncles which occurred often in 
former times in connection with profuse otorrhoeas has become extemely 
rare since we treat otorrhoea with boric acid. They arise probably only 
from coarse external manipulations. 



Otitis Externa Diffusa. 113 



The Different Forms of Otitis Externa Diffusa*. 

2.4 per cent of all ear patients according to my statistics suffered 
from primary otitis externa diffusa. We call it primary, in that it is free 
from suppuration of the middle ear. Otomycosis and otitis externa 
crouposa, both of which will be described separately, are included in this 
figure. Of the above number 80.5 per cent were adults, 19.5 per cent 
children. In 70.5 per cent one ear, in 29.5 per cent both ears were af- 
fected. 

This disease was formerly diagnosed very frequently especially by 
general practitioners. It became more and more rare in the statistics of 
otologists the more carefully the origin of the secretions, which were 
found in the external meatus, was investigated. A large number of sup- 
purations of the middle ear are difficult to diagnose and may lead to such 
mistakes. Only a few of them may here be mentioned: Cases of otitis 
media purulenta acuta which soon after recovery caused a secondary oti- 
tis externa, or whose secretions still remained in the meatus. Further- 
more suppurations of the middle ear in children of only a few years, in 
whom the drum membrane can not be completely examined, and in whom 
only the air douche according to Politzer, or movements of swallowing 
while syringing the ear, indicating that the fluid runs down the nose and 
throat, can give an intimation of the presence of a perforation of the 
drum membrane. Furthermore chronic suppurations of the middle ear in 
which the drum membrane is preserved, but has grown to the inner wall 
of the drum cavity in such manner that the margo tympanicus protrudes 
freely. Suppurations which are difficult to diagnose are especially those 
with defects of the membrana flaccida Shrapnelli which are overlooked 
so often and so easily, that their frequent occurrence was absolutely un- 
known even to otologists only three decades ago. Mistakes as to the origin 
of the secretions in otitis externa diffusa may finally be made when there 
are fistulas in the external meatus which either lead to spaces of the 
middle ear located very closely to the wall of the canal or from foci of 
suppuration in the surrounding soft tissues, abscesses by gravitation, 
below the mastoid process, suppurations of the parotid gland, etc. 

It is well known that secondary otitis externa diffusa developes very 
frequently under the influence of a suppuration of the middle ear with 
perforation of the drum membrane. This occurs rather regularly if no 
treatment takes place and the secretions which remain in the meatus de- 
compose. The lining epidermis of the bony meatus becomes macerated un- 
der the influence of the decomposed secretions and the surface becomes 
excoriated. Granulations will form if this condition lasts long enough, and 
if it is especially bad, that is if permanent warm applications and great 
uncleanliness persist, the whole surface of the meatus up into the concha 
may become covered with diphtheritic membranes, as seen sometimes in 
children who are brought in from the country. Permanent constrictions 
and atresia of the meatus mav be the result. 



114 Otitis Externa Diffusa. 



All authors at present agree that mucopurulent secretions in the 
auditory canal originate in the middle ear, except in very rare cases of 
formation of granulations and polyps which may arise in the meatus 
itself, while the middle ear is intact. 

The genuine otitis media diffusa, excluding even otomycosis and 
otitis externa crouposa is a disease of many different forms which prob- 
ably depend upon the causes to which they owe their existence. This 
view was pronounced long ago by v. Troltsch. 

We sometimes find gatherings of very fetid masses of ear wax con- 
verted into a fluid, which from time to time reappear and fill out the 
depth of the meatus no matter how carefully we remove them and disin- 
fect the whole space. In other cases we find only some serous secretions 
with increased new formation of epidermis. In others the walls of the 
meatus are so much swollen that they touch each other while not a drop 
of secretion may be found. Again ulcers may be seen which are always 
at the floor of the meatus, at its highest point, that is where the cartilag- 
inous meatus passes over into the bony meatus. The bone in some cases 
is felt and seen lying bare to a large extent at the bottom of these ulcers. 
The ulcers are most probably provoked by continuous traumatic lesions. 
The patients are always very old people who repeatedly admitted having 
inflicted them. Sometimes serous secretions are found in the re- 
gion of the external meatus where the glands are. They sometimes are 
purulent, as I became convinced in a case which I examined microscopi- 
cally. In some of these rare cases the secretion may be seen appearing 
at the openings of the glandular ducts, whenever the auricle is rolled up 
and compressed. 

Granulations in whose origin the middle ear does not participate, 
may form in the meatus when a foreign body with sharp corners is pres- 
ent, which somebody has tried to remove, or in connection with neglected 
furuncles. 

A few very rare occurrences must here be mentioned, namely pem- 
phigus, condylomata lata and other forms of luetic affections of the exter- 
nal meatus. Herpes is mainly seen on the auricle. The appearance of 
hemorrhagic blisters in the bony meatus proved always to be a part of an 
acute inflammation of the middle ear. 

I saw four cases of necrosis of the os tympanicum where parts of 
this bone were expelled as sequestra. 

The first case was that of a hereditarily syphilitic child of one year 
and three months. The sequestrum proved to be the whole annulus tym- 
panicus which absolutely looked like that of a new-born. The necrosis 
must have taken place during the first weeks of life. 

In another case I extracted a sequestrum from the meatus of a child 
of seven years which formed a part of the os tympanicum, and of which 
fig. 46 shows a front and rear view. You see clearly on its rear surface 
a part of the sulcus tympanicus. Nevertheless the drum membrane was 



Otomycosis. 115 



found connected with the new formed bone, and whisper could be heard 
at a distance of three meters after the granulations which filled the meatus 
had disappeared. 

Thermical and chemical besides mechanical influences must be named 
among the causes for the development of otitis externa diffusa, but espe- 





Fig. 46. 

Sequestrum of the anterior wall of the meatus and a part of the tube. 
a anterior surface, b post, surface containing the sulcus tympanicus. 

cially the entrance of water into the meatus is most important, because, 
especially in children, it can be removed only very incompletely from the 
recessus. This is the reason why, in infants who are only a few weeks 
to a few months old, we not very rarely find an extremely fetid secretion 
from the ears in which the middle ear has no part whatsoever, but which 
is mainly caused by water and vernix caseosa which remained in the 
depth of the meatus. Most favorable for the development of otitis ex- 
terna are : baths, local steam-baths of all kinds, warm moist applications, 
etc., as they all cause the epidermis to macerate. 

The real causa efficiens in all different forms of this disease are 
micro-organisms, especially saprophytes. They play the same part in the 
propagation of a fetid secretion from the meatus as do the hyphomy- 
cetes in otomycosis. 

The treatment of otitis externa diffusa is accordingly very simple. 
It consists in antiseptic injections, drying out the meatus very carefully 
down to the inner end of the recessus with a probe wrapped with cotton, 
and insufflation of dry boric powder, which absorbs the new formed 
secretions. The ulcers on the floor of the meatus are dusted with iodo- 
form powder and the meatus is guarded against further manipulations. 
Luxuriant granulations are removed with the snare. 



& j 



Otomycosis. 

A form of otitis externa diffusa, the etiology of which has been very 
carefully investigated, is that form of inflammation which is caused by 
the development of a mould in the external meatus. 

Moulds may develop under special circumstances in the caverns of 
a human lung, and in the organs of respiration of birds. In the same 
manner hyphomycetes may grow in the bony meatus and on the drum 
membrane, on whose surface it may spread over a large extent. Mould 
does not always cause inflammation as long as it is confined to the wall 



116 



Otomycosis. 



of the meatus. It does not cause any symptoms whatsoever in more than 
one-third of the cases according to my observations. 

In all ear patients whom I saw during 24 years, I found the presence 
of mould in the bony meatus macroscopically and microscopically in no 
less than 0.7 per cent, including the numerous cases where there were 
no symptoms. Only 4 per cent of them were children. Both ears were 
affected in one-third of the patients. 

The number of different forms of mould which grow in the meatus 
is pretty large. Siebenmann who re-examined my histories and specimens 
of former years found the genus aspergillus most frequently. They were 
aspergillus fumigatus and a. niger, less frequently a. nidulans and flavus, 




Fig. 47. 

Aspergillus nidulans (according to Siebenmann). 

a sporangiophore, b conidiophor with sunken top, c young sporangiophore, d and e free conidia. 

more frequently verticillium Graphii which was pictured long ago by 
Steudener though under a different name, two cases with mucor and one 
case with penicillium are also mentioned. 

The presence of the mould in the meatus can easily be discerned by 
examination with the ear speculum. Aspergillus fumigatus which is found 
most frequently in the meatus and usually does not cause any symptoms, 
forms a grayish green sod with its closely arranged little heads. Aspergil- 
lus niger and flavus have much larger black or yellow heads and form a 
very rich mycelium which usually fills out the bony meatus and covers the 
drum membrane. The verticillium is mostly enclosed in cheesy, grayish 
yellow masses of secretion and mucor in brownish masses. 

Figures 47 to 49 give you elegant microscopical views of aspergillus, 
verticillium and mucor, as they are obtained from the meatus. 

The meatus and the drum membrane were free from signs of inflam- 
mation in those cases which did not show any symptoms ; proof enough 



Otomycosis. 



117 



for the fact that a dermatitis is not necessary for the growth of the 
fungi. 

The formation of mould was never observed in cases of fresh sup- 
purations. 




Fig. 48. 

Verticillum Graphii (according to Siebenmann) . 
a formation of a trunk, b young conidiophore, c old spores, d old mycelia. 





Fig. 49. 

Mucor septatus (according to Siebenmann). 
a formation of rhizoides, & columella, c sporangium, e open columella. 

Some kind of culture medium however seems necessary for the 
growth of saprophytic fungi, according to my experience. Mould was 
found not very rarely on pieces of plants which people insert so fre- 



118 Otomycosis. 



quently into the meatus for medicinal purposes, in other cases it located 
first on dry crusts. Most frequently, in more than three-fourths of all 
cases which I observed, instillations of oil, glycerine or other fatty sub- 
stances preceded the development of the mould. The botanist Harz 
obtained a very luxuriant culture of aspergillus niger on lard. The 
mycelium which is found in the meatus frequently contains a great many 
drops of oil in its tubules. Therefore we are justified in the supposition 
that the oil is the first culture medium for the saprophytic fungi, and only 
after they have grown strong enough are they able to encroach upon the 
epidermis of the meatus and drum membrane. 

The symptoms of inflammation in the meatus begin the moment the 
mycelium encroaches upon the life tissue and may develop to various 
degrees. They are confined, in a number of cases, to an increased exfo- 
liation of epidermis and a moderate amount of secretion of serum. There 
is at the same time intense itching in the meatus and some deafness de- 
pending upon the occlusion of the canal. A moderate amount of pain is 
felt while the amount of secretions is increasing, finally large glove finger 
like casts of the meatus may be spontaneously expelled (compare fig. 





Fig. 50. 
Casts of the external meatus formed by mycelia of mould. 

50), after which the symptoms diminish. This whole process may repeat 
itself from time to time for months and years. 

The meatus and the drum membrane appear irregularly reddened 
and partly stripped of their epidermis after such a cast has been removed 
by injections. A great deal of epidermis is produced and cast off during 
the next few days from the whole surface of the meatus. The ejected 
lamellae of epidermis, when examined under the microscope, are found 
more or less perforated by the mycelium. Formerly, when no antiseptic 
fluid was used for syringing, considerable swelling and pain in the 
meatus were often observed after syringing. I have not again seen such 
serious aftereffects since I use 4 per cent boric acid solution for injection 
and some antiseptic afterwards. The meatus and the drum membrane 
usually appeared perfectly normal after eight days of treatment. 

The treatment of cases of mould is more tedious, when the vegetation 
has spread through an old large perforation in the drum membrane 
over the cavities of the middle ear. New recurrences may appear from 
time to time for many months, notwithstanding the most careful continu- 
ous mechanical cleaning by means of the jet of the syringe and the use 
of remedies fatal to parasites. This is not surprising if we consider the 
secluded position and sinuosities of the infected cavities. 



Otitis Externa Crouposa. 119 

Not alone an otitis externa diffusa but an acute perforative suppu- 
ration of the middle ear was observed in some cases in which mould grew 
over the meatus and drum membrane. It is caused by threads of the 
mycelium growing into the drum membrane (Politser). The mould 
does not seem to progress through the small perforation caused thereby 
in the drum membrane, on account of the profuse secretion, nor does it 
seem to spread into the cavities of the middle ear. Yet a profuse muco- 
purulent discharge may last for many weeks, and may under favorable cir- 
cumstances lead to all the serious complications which are liable to de- 
velop in the disease. Fortunately all cases which I observed up to to-day 
recovered without further disturbance. 

The therapy of otomycosis consists in careful mechanical removal 
of the mould by means of daily injections of warm 4 per cent solution 
of boric acid. We need furthermore the repeated action of some remedy 
which will kill the parasites, as the mycelium of the mould has partially 
penetrated into the living tissue. A 2 per cent solution of salicylic acid in 
alcohol has best answered the purpose. It is poured into the meatus not 
heated twice a day and left there for 10 minutes. At first considerable burn- 
ing is felt which soon stops. In about a week recovery is usually complete, 
after the whole surface of the meatus has been repeatedly cast off. 

Salicylated alcohol is generally well tolerated even when there is a 
large old perforation of the drum membrane, and the mucous membrane 
of the middle ear is replaced by epidermis. In case it should cause 
strong reaction we have to confine ourselves to daily injections of solu- 
tions of boric acid. 

Otitis media purulenta acuta following otomycosis requires the same 
treatment as the genuine acute suppuration of the middle ear. 

Otitis Externa Crouposa. 

Otitis externa crouposa is a peculiar form of reaction caused by very 
different kinds of irritations which may act on the meatus and drum 
membrane. It therefore requires a summary discussion here. 

It is characterized by the formation of a coagulated fibrinous exuda- 
tion in the bony meatus and on the drum membrane. This process re- 
peats itself several times in rapid succession accompanied by signs of 
violent local inflammation. 

Thick semi-transparent membranes and often regular casts are formed 
in the bony meatus with accurate impressions of the tympanic mem- 
brane, accompanied by terrible pains which irradiate in the surroundings, 
while the walls of the canal are swollen and the temperature of the 
patient rises to moderate fever. This sometimes occurs in connec- 
tion with other diseases of the external meatus, like furunculosis, 



1 ) "Fibrinoses Exudat auf dem Trommelfell und im Gehorgang," by Bezold. Virchow's Arch. 
Vol. 70, 1877, and ,,Beobachtungen iiber Otitis externa crouoosa," by SteinhofT Arbeiten, a. d.med 
klin. Instit. d. Univ. Miinchen, edited by V. Ziemsen & Bauer, Vol. II. 1. Half. 1890. (35 cases 
of my observation. 



120 Otitis Externa Cronposa. 

formation of hemorrhagic blisters in the meatus and drum mem- 
brane, otomycosis, cauterisation of the roots of polyps with ar- 
gentum nitricum or liquor ferri sesquichlor. After trauma or 
application of dry heat, sometimes in the beginning of acute per- 
forative or non-perforative inflammations of the middle ear, sometimes 
genuine, that is without any of the causes here enumerated. The forma- 
tion of the pseudo-membranes repeats itself from two to five times at 
short intervals (usually every second day) while at the same time there 
is more or less discharge of serum, which, after the formation of casts 
has ceased, becomes purulent for a short while, when the process closes 
with quick recovery. The membranes and casts are very moist, semi- 
transparent, of yellowish color and have a number of hemorrhagic red 
spots especially on the part which corresponded to the drum membrane. 
They shrink quickly and become opaque in air or in alcohol. They offer 
strong elastic resistance to teasing with needles, and are tough, which 
is contrary to what we know of epidermoid membranes. The membranes 
which are cast off first, when examined under the microscope, consist 
almost exclusively of a tender network of threads which show all the 
chemical reactions of coagulated fibrin. Those which are cast off later 
on contain more and more numerous pus corpuscles and epidermoid cells. 

The removal of the membranes with the syringe or with a forceps 
is easy, but usually causes considerable pain for a short while. The audi- 
tory canal and epecially the surface of the drum membrane are after- 
wards found covered with extravasations of blood and even large hemor- 
rhagic blisters and are partially excoriated. The removal of the 
membranes is sometimes followed by considerable swelling, so that the 
meatus becomes a narrow slit, after which the pains decrease and increase 
again when a new membrane is formed. The formation and casting off 
of a large amount of epidermis is noticed toward the end of the disease. 

During the height of inflammation hearing is considerably dimin- 
ished, also in those forms which are apparently genuine, it becomes nor- 
mal when all is over. The duration of the disease is rarely longer than 
two or three weeks. 

As to the frequency of its occurrence, I saw otitis externa crouposa 
in 0.5 per cent of all ear patients which I treated up to 1892 ; 85 per 
cent of them were adults, 15 per cent children below 15 years. The affec- 
tion was noticed in both ears in 8.6 per cent. It occurs most frequently 
in spring like croupous pneumonia (according to v. Ziemssen). 

The formation of croupous exudations in the meatus as a part of 
otitis is noticed much more frequently at times when there is an epi- 
demic appearance of influenza otitis. 

There is a very remarkable fact that otitis externa crouposa became 
successively rarer within the last decades, and I have not seen such 
voluminous casts within the last few years as formerly. It is possible 
that this is the effect of a more severe antisepsis, which was unknown in 



Otolithiasis. 121 



the beginning of my practice, but the gradual disappearance of the dis- 
ease may as well be the expression of a change of the "genius epidemicus" 
since diphtheria also has accepted a milder character. 

The formation of a fibrinous exudation on the surface of the meatus 
and drum membrane is of general nosological interest, because it is the 
only locality where, probably on account of its exceptional thinness and 
the superficial position of its blood vessels, the cutis is able to produce 
fibrin, similarly to the mucous membranes and serous membranes. 

It is very probable that in the quick formation of an uninterrupted, 
thick layer of fibrin we can recognize a means of protection by enclosing 
infectious germs and keeping them away from the living tissues. 

A few cultures were made which once showed the staphylococcus 
pyogenes aureus and once bacillus pyocyaneus which was also frequently 
found by other authors. I am doubtful, however, whether the latter is 
really the cause of the disease as I often saw the characteristic bluish 
color of the epidermis of the meatus in preantiseptic times, without the 
formation of a croupous exudation. 

The therapy of otitis externa crouposa consists in careful removal 
of the membranes and fluid secretions by means of injections with boric 
acid solutions, and, after the meatus is carefully dried out, insufflations 
of boric acid or iodoform powder. The very violent pains and the other 
symptoms of inflammation at the height of the process require continu- 
ous application of the ice bag and daily doses of morphine. Air douche 
by means of Politzer's method or through the catheter are used in our 
clinic from the beginning, whenever there is an acute inflammation of the 
middle ear at the same time. 

Otolithiasis. 

Concretions of chalk in the external meatus are very rare. I saw 
them only twice. 1 The drum membrane and the meatus in my two cases 
were found intact, while in those few observations which are on record 2 
there was at the same time a chronic inflammation of the middle ear. 

In some cases there were old plugs of cotton in which hard concre- 
tions of chalk had formed ; in my two cases they were found enclosed in 
thick layers of epidermis, the center of which was a cheesy mass. It 
seems probable that a special kind of bacteria plays the part of a go- 
between in their exceptional occurrence in the meatus on account of the 
presence of a great many cocci in form of zoogleamasses, as in the forma- 
tion of tartar on the teeth, or concretions in the tear ducts and rhino- 
liths. 

There was fetid secretion in the meatus in both of my cases. A 
cone-shaped growth had formed in the meatus of my second patient in 



1) „Lithiasis des ausseren GehSrgangs" v. Bezold. IV. Congres internal;, d'otolog. Bruxclles 
1888. 

2) Kretschmann, Verhandl. d. Deutsch. Otol. Gesellschaft in Wiesbaden 1903, page 57. 



122 Otolithiasis. 



consequence of the irritation caused by the sharp corners and edges of 
the foreign body and of the frequent manipulations of the patient. A num- 
ber of very irregular hard particles up to half a centimeter in length were 
removed in both of my cases, partly by means of the syringe, partly by the 
spoon and forceps. They looked very much like carious bone as to color 
and roughness, and also as to their perforated and trabeculated surface. 
A copious development of gas on adding muriatic acid under the micro- 
scope showed that they consisted partly of chalk. 

The great similarity of the otoliths with sequestra of spongy bone 
might very easily cause them to be mistaken for caries necrotica of the 
temporal bone, especially if there is at the same time an extensive destruc- 
tion of the drum membrane. 



LECTURE XIV. 

Diseases of the Drum Membrane. 
General Part. 

Gentlemen: — Only the smallest number of diseases of the drum 
membrane are confined exclusively to this membrane. The great major- 
ity constitute either a part of diseases of the meatus as we saw in describ- 
ing the different forms of otitis externa diffusa, or, which is still more 
frequent, the visible changes of the tympanic membrane are simply that 
part of the diseases of the drum cavity and its adnexa, which is accessi- 
ble to our eye. 

Myringitis acuta and chronica which are usually differentiated in 
text-books as independent diseases, can only be separated incompletely 
from otitis media acuta and chronica in the way of differential diagnosis. 
They are represented therefore in the otological statistics in variable 
numbers which are mostly so small that I think it is preferable not to sep- 
arate them from inflammations of the middle ear. 

The so-called acute myringitis especially in influenza otitis often has 
in the beginning the characteristical appearance of a fresh inflammation 
of the drum membrane. Later on in the course of the disease the symp- 
toms of a simultaneous affection of the middle ear, like deafness and 
secretion in the drum cavity, appear, although it is true that they are 
sometimes slight and pass over quickly. 

Growths on the surface of the drum membrane were formerly con- 
sidered characteristical for chronic myringitis. They occur in the great 
majority of cases in connection with large perforations of the drum mem- 
brane, the margins of which, during the process of healing, have become 
partially adherent to the granulating surface of the promontory. 

For these two reasons I prefer to desist from describing an inde- 
pendent myringitis acuta and chronica. 

Deposits of chalk in the drum-membrane and retractions without 
considerable diminishing of the power of hearing must be ascribed to pre- 
vious suppurations of the middle ear or previous affections of the Eusta- 
chian tubes respectively. 

123 



124 Traumatic Rupture of the Tympanic Membrane. 

We refer to the chapter on congenital atresia of the meatus and rud- 
imentary auricle as to congenital aplasia of the drum membrane. 

Traumatic Rupture of the Drum Membrane. 

Traumatic ruptures of the tympanum were found in 0.5 per cent of 
all ear patients whom I saw. Other authors recorded more, up to 2 per 
cent. 

It is surprising that injuries of the membrane are not more frequent 
considering its delicacy, its exposed position in an open canal which is 
comparatively short and wide in the human, compared to that of mam- 
mals. The resistency of its unelastic fibres compared to the thinness of 
the membrane is considerable (Schmiedekam). Tears in the mem- 
brane caused by sudden changes of air pressure occur much more easily 
in large scars than in the normal membrane. 

It is comparatively well guarded against direct injuries by the tra- 
gus, the antitragus and the antihelix which are able to ward off the 
thrusts of pointed objects, like branches of trees, blades of straw, etc., on 
the other hand by the zig-zag shaped course of the meatus itself which will 
divert the direction of the thrust away from the axis of the meatus and 
thereby away from the tympanum. The tragus especially is situated like 
a valve before the entrance of the meatus. Injuries are therefore seldom 
caused by falls or blows of the head against some pointed object, accord- 
ing to my experience. 

Direct injuries to the drum membrane are much more frequently 
caused by unreasonable digging with pen-holders, matches, hair-pins, 
the temples of spectacles, etc. Extensive tearing of the membrane in this 
manner is not at all rare. It is necessary to warn the patient against 
using any instruments, especially in cases of pruritus meatus, from which 
so many people suffer. 

The most incredible things can be seen. A patient came to see me on 
account of hemorrhages from the meatus. He had torn away the whole 
posterior half of the drum membrane from its attachment to the pe- 
riphery with a temple of his spectacles the evening before. Another case 
is on record where a man extricated the anvil in scratching the ear with a 
hair pin. 

Every otologist sees a certain number of ruptures of the drum mem- 
brane caused by awkward attempts at extraction of foreign bodies which 
had lodged in the meatus. It is fortunate if no other damage has been 
done in the drum cavity. 

A simple thrust with a long pointed object, a hat pin, etc., into the 
depth of the meatus very exceptionally causes injuries in the drum cav- 
ity, tegmen tympani or oval window. The round window, as we saw, 
is protected by its hidden position. Abundant discharge of fluid follow- 
ing directly after the injury, points to the occurrence of such an accident. 

The compilations of Passozv, with which my observations concur, 



Traumatic Rupture of the Tympanic Membrane. 125 

showed that the ruptures of the front half of the membrane occur equally 
as often as those of the rear half as a consequence of direct injuries. 

Indirect ruptures of the membrane, i. e., ruptures as effects of some 
injurious power at a distance are much more frequent than from direct 
thrusts of some pointed object. A relatively moderate sudden compres- 
sion or rarefaction of the air in the meatus is sufficient to burst the tym- 
panic membrane. The greatest number of ruptures are therefore due to 
slaps on the ear, furthermore diving into water, hitting of trap-doors 
against the side of the head. Sudden rarefaction of the air in the meatus 
compared to that in the middle ear, caused for instance by kisses on the 
ear, or air-douches through the tube may cause ruptures, though only in 
cases of scars, which have not the same power of resistance as a nor- 
mal membrane. Furthermore a number of ruptures are caused by explo- 
sions. Gun shots and cannon shots can produce ruptures only when the 
ear is on the side of the direction of the shot. The small mortars which are 
often used to fire salutes on festival occasions seem to be especially danger- 
ous to the drum membrane, as I repeatedly saw multiple ruptures of both 
membranes in people who stood close by, in shooting. Ruptures were fur- 
thermore observed after strokes of lightning (Biirkner) . There is no 
sufficient explanation for the rupture of the drum membrane which was 
often observed in people who came to death by hanging. 

Indirect ruptures, according to the experience of all authors (Pas- 
sow) are located the most frequently, in more than one-third of all cases, 
in the anterior lower quadrant of the drum membrane. The explanation 
for this fact is found in the stable position of the axis of the meatus ; the 
anterior lower quadrant, especially the region of the triangular reflex, is 
the only spot on which the impact of the compressed air bounds in a 
perpendicular direction. The opening is therefore frequently in the re- 
flex itself. The numerous exceptions to this rule are explained by the 
fact that pathologic membranes with extensive scars and atrophic parts 
in different quadrants will tear much more easily than normal membranes. 

The appearance of fresh ruptures is very characteristical and can 
easily be differentiated from that of spontaneous perforations and destruc- 
tions caused by suppurations of the middle ear. In the latter case the 
perforation is round or kidney-shaped, in ruptures it is irregularly torn or 
lancet shaped, with sharp margins which usually show several extravasa- 
tions of blood, if the rupture did not take place in a scar containing very 
few blood vessels. The mucous membrane of the drum cavity which is 
seen through the rupture is yellow, like a bone, not swollen or red. Only 
the vessels of the handle of the mallet may be injected, the whole remain- 
der of the membrane looks normal. A whistling, shrill noise of perfora- 
tion can be heard when Valsalva's test is made in cases where a perfora- 
tion is due to a suppuration which still may exist or have passed. A low 
blowing sound which can be heard with the auscultation tube only, is 
characteristic of a traumatic rupture. 



126 Traumatic Rupture of the Tympanic Membrane. 

The most important subjective symptom in ruptures is very violent 
pain which is usually felt only in direct ruptures at the moment of their 
formation, and must probably be ascribed to the simultaneous extensive 
touching of the walls of the bony canal which are very sensitive. It can 
be entirely absent if the latter is not touched. In indirect ruptures there 
is usually no pain. The patients only complain about a feeling of dullness 
in the ear. Permanent noise in the ear exists often, rarely however dizzi- 
ness and vomiting. The subjective noises in rupture after explosions are 
stronger, which must probably be attributed more to the simultaneous 
affection of Corti's organ by the detonation than to the lesion of the 
sound conducting apparatus. A high singing noise may remain for a long 
time together with a hyperesthesia for the same sound. 

Hearing for whisper is more or less diminished in the beginning. 
In 13 patients whose hearing became normal later on (NotherV) 
it had been from 15 centimeters to four and one-half meters soon after 
the injury. 

The result of the tuning-fork tests is very characteristic and oi 
great physiologic interest. 

More than an octave, from 12 v. d. to 32 v. d. and more, at the lower 
limit of the sound scale is always completely lost to hearing by air con- 
duction, while hearing by bone conduction for this part of the scale and 
for all forks of higher pitch, as high as they can be used for examinations 
of bone conduction, is much prolonged throughout. Rhine's test, on ac- 
count of this preponderance of bone conduction, is either very much 
shortened positive, or else it is negative, and in Weber's test the fork is 
heard in the injured ear. 

All these phenomena are found in all ruptures of the drum mem- 
brane including those which occurred without any large amount of vio- 
lence. They disappeared again when the rupture was closed. They give 
us therefore the experimental proof that they, together with the simulta- 
neous diminishing of hearing for whisper are exclusively dependent upon 
the disturbance of equilibrium of the sound conducting apparatus. The 
traction of the tensor tympani muscle overbalances its antagonists (the 
stapedius muscle and the circular fibres of the drum membrane) on ac- 
count of the tearing apart of a number of the radiar fibres of the drum 
membrane, and the whole apparatus becomes one-sided and fixed. (The 
same functional disturbances are observed in otherwise normal ears when 
the tensor tympani muscle is wilfully contracted, which some people are 
able to do.) 

Recovery from ruptures of the drum membrane, caused by compres- 
sion of air in the meatus or explosion, always takes place without inter- 
fering suppuration if all damaging influences from the outside are kept 
away. It is usually completed within a few weeks, when the opening is 



I) Zeitschrift f. Ohrenhlk. XXIII. page 19. 



Traumatic Rupture of the Tympanic Membrane. 127 

closed and normal hearing has been restored. Closing of the opening 
does not take place if the perforation is very extensive and if it occurred 
in very large scars. 

Suppuration of the middle ear is more frequently observed in con- 
nection with direct ruptures of the membrane by means of some sharp 
pointed object. The germs of infection are carried into the drum cavity 
by the foreign body, while they are absent in indirect ruptures. 

These facts, which are gained by observation, indicate our therapy 
in direct and indirect ruptures of the tympanic membrane. To keep away 
everything injurious which might penetrate from the outside through the 
opening into the drum cavity must be our exclusive object. Touching of 
the rent must be avoided. Extravasations of blood remain untouched around 
the opening and we can later on watch their excentrical migration, which 
corresponds to the growth of the cutis in the meatus (compare page 109) 
towards the periphery of the drum membrane, and from there to the wall 
of the meatus. A very loose ball of cotton which fills the cartilaginous 
meatus and is retained by the elasticity of its fibres only, affords, accord- 
ing to our experience, a sufficient safeguard against infection as long as 
the drum cavity is open. I never saw any damage arising from air douche. 
Nevertheless it is better to avoid it as it does not furnish any advantage, 
as long as the drum cavity is free from secretions. The penetration of 
fluids into the middle ear is absolutely harmful. The use of the syringe 
and instillations are to be avoided and the patients warned to be careful 
in washing and bathing. The treatment has to be the same as in the gen- 
uine otitis media purulenta acuta whenever suppuration has set in, as 
often happens in direct injuries. An injection may become directly dan- 
gerous to life when there is a flow of serum after an injury with some 
pointed object. 

The ruptures of the drum membrane which are observed after a 
trauma to the surface of the skull like a fall or a blow on the head require 
separate discussion. They occur by transmission of power and are there- 
fore counted among the indirect ruptures. 

A tear in the center of the tympanic membrane may be produced by 
a sudden shock on the skull without any other injury. I saw a large oval 
opening which had freshly occurred after a fall on the occiput from a 
street car. 

The rupture of the drum membrane is a part of the fracture of the 
bones on the base of the skull in the largest number of cases of similar 
injuries. 

The tear is usually a continuation of a fracture of the periphery and 
in most cases is located on top. Lesions of the sound-conducting appa- 
ratus, like luxation in the joint between the hammer and the anvil, which 
I had a chance to see on the cadaver, occur sometimes in such cases. Con- 
tinuations of such fractures through the tegmen tympani and the tem- 
poral bone are still more important. A fracture through the temporal 



128 Scalding, Destruction of the Membrane by Chemicals. 

bone injures also the labyrinth, since according to Scheibe, the line of 
fracture usually follows the cavities in the bone. Serious symptoms of 
commotion of the brain, like long lasting unconsciousness, vomiting, ter- 
rible dizziness after awakening, usually indicate the great extent of the 
injury. Hemorrhage may occur from the ear, or sometimes, according 
to the course of the fracture from the nose and mouth. Discharge of 
liquor cerebrospinalis is noticed in rare cases. 

The result of the tests of the function will indicate whether or not 
the injury has extended to the sound-conducting apparatus or to the laby- 
rinth. A very pronounced restriction of the lower limit by air conduc- 
tion, together with an increase of bone conduction, inform us that the in- 
jury is confined to the drum membrane and the chain of ossicles. Bone 
conduction on the other hand is shortened in commotion of Corti's organ, 
and we find the signs of complete deafness in one ear, which will be dis- 
cussed in the chapter on necrosis of the labyrinth, whenever a fissure goes 
through the labyrinth. 

The penetration of anything which may be harmful has to be avoided 
much more carefully, when such serious complications are present than 
even in ruptures of a drum membrane. Instillations of fluid or syringing 
will find all doors open to produce panotitis and in connection with it fetal 
meningitis. 

Scalding and Destruction of the Drum Membrane by 
Various Chemicals. 

Scalding of the drum membrane occurs very easily when hot water 
is spilled over the side of a person's head. 

There was great discrepancy in all cases of this kind which I saw, 
there were but few traces of scalding on the walls of the meatus, the 
auricle and its surroundings, while there was extensive destruction of 
the drum membrane. After a few days one could see but slight traces of 
the scalding on the first named places, while the drum membrane was 
nearly completely destroyed. A large perforation, the shape of a horse- 
shoe had formed leaving nothing but some of the thicker parts, the limbus 
and the handle of the hammer with a small remainder at the upper part of 
the membrane. A yellow piece of shriveled up tissue hung from the lower 
end of the isolated handle of the hammer, and was expelled during the 
next few days. 

There is a very simple physical explanation for this weak power of 
resistance of the drum membrane against heat. It is due partly to its be- 
ing thin and partly to the nature of the medium on its inner surface, 
namely, the air, to which a difference of temperature cannot be transmit- 
ted as quickly as if there were some solid body as in the cutis of the 
meatus. 

A few days after the scalding there is abundant purulent secretion 



Scalding, Destruction of the Membrane by Chemicals. 129 

from the drum cavity whose mucous membrane appears diffusely red- 
dened or much swollen. 

It seems that the cells which are further distant do not take part in 
the process, if treatment begins in time, under which condition the dis- 
charge stops in a few weeks. The opening in the drum membrane dimin- 
ishes during the same time and becomes rounder. In one case I saw it 
even closed for some time. Later on, when the margins become definitely 
epidermized, the hole becomes a little larger again. 

The disturbance of hearing which is considerable, corresponding to 
the swelling of the mucous membrane and the size of the opening, disap- 
pears to a great extent, and remains in accordance with the size of the 
opening. 

Destruction of the drum membrane happened many times when bot- 
tles containing acids or alkali, like hydrochloric acid or caustic ammonia, 
were mistaken for ear drops and poured into the meatus. 

The effect of these chemicals is not confined to the drum membrane 
like that of hot fluids, but extends into the cavities of the middle ear. In 
some cases which I saw only a long time after the mishap, suppuration 
had lasted for years. The drum membrane was nearly destroyed, the mu- 
cous membrane was granulating ; there was great loss of the power of 
hearing. 

Four cases of terrible destruction of the membrane or middle ear by 
chemicals poured into the meatus were recorded from Warsovie within 
the last few years (by Jilrgens 1 ). They concerned young men who 
poured concentrated muriatic acid into the meatus in order to make them- 
selves unfit for military service. In all cases there was necrosis of the 
deeper parts of the meatus, and extensive necrotic destruction of the walls 
of the middle car. The wall of the carotid artery was destroyed to a 
great extent in three cases which caused repeated severe hemorrhage from 
the ear, nose and mouth. Two patients soon died from meningitis, the 
third one bled to death. In the last case there was paralysis of the facial 
nerve. There was a hemorrhage from the bulb of the jugular vein in the 
fourth case connected with symptoms of pyemia. The hemorrhage could 
be stopped in this case by means of tamponade of the meatus. 



1) Monatsschr. f. Ohrh., 1902. Nos. 1 and 4, as also 1904, No. 10. 



LECTURE XV. 

Diseases of the Middle Ear. 

General Part and Introduction. 

Gentlemen: — The extensive and complicated cavities of the middle 
ear are the most frequent location for diseases of the organ of hearing. My 
otological statistics which extend over 24 years show that 66.1 per cent 
of all patients whom I saw during this time suffered from affections of 
the middle ear. 

This large percentage of diseases in this region closely coincides 
with all the recent otological statistics and finds its explanation on one 
hand in the wide port of entrance to the cavities through the tube, on the 
other hand in the frequent, almost regular participation of its tender lin- 
ings in general infectious diseases, especially the acute exanthemata of 
childhood. Extensive and permanent destructions which curtail its func- 
tion and even involve a constant menace to the whole organism, devel- 
op more easily and more frequently in the ear than in any other organ of 
the body in the course of those diseases. 

There is no agreement amongst authors as to the classification and 
nomenclature of diseases of the middle ear. 

All inflammations of the middle ear were called catarrhal in former 
years. Even in v. Troltsch's books one finds besides an acute and a 
chronic suppurative catarrh, an acute and chronic otitis media. 

As the lining membrane of the cavities of the middle ear is a direct 
continuation of the mucous membrane of the pharynx, it was also called 
a mucous membrane. This name is in keeping with the cartilaginous 
tube where the lining is thick and has many folds, is covered with several 
layers of ciliated epithelium, has many acinous glands and includes a di- 
rect continuation of the adenoid tissue of the naso-pharynx. The char- 
acter of the lining however changes in the bony part of the tube. In the 
upper part of the cartilaginous tube the folds disappear and are absent in 
the bony part, where a fusion of the membrane with the periosteum, and 
a disappearance of the glands takes place. There are no glands in the 
drum cavity nor in any of the other cavities of the middle ear. Ciliated 

130 



The Lining of the Spaces of the Middle Ear. 131 

epithelium is found only at the floor of the drum cavity, where it is a 
continuation of that of the bony tube, and has one layer. On the sides it 
becomes lower and lower in all directions until it changes into one layer 
of very delicate pavement epithelium, which covers the inside of the drum 
membrane, the ossicles, the promontorial wall as well as all pneumatic 
cells of the temporal bone. The very thin and delicate lining is united 
everywhere with the periosteum. Kessel, who examined the pavement 
epithelium of the drum cavity, found that it has stomata which communi- 
cate with the system of lymph vessels and has an endothelial character. 
Kessel calls the lining of the drum cavity an "organ of secretion and 
movement" in so far as it has ciliated epithelium whose direction of 
movement is towards the tube, and an "organ of absorption" where it is 
simple pavement epithelium 1 . 

This way of looking at the histological findings coincides with our 
clinical experience. It shows that we have to ascribe a great power of ab- 
sorption to the lining of the middle ear and also a great recuperative 
power, as we shall see later on in describing acute otitis media in the 
course of the exanthemata in children. 

One word as to the normal secretion of the lining of the middle ear. 
It is only in the cartilaginous tube that we expect to find viscid mucus. 
The osseous tube, the drum cavity, and all the other cavities do not nor- 
mally produce any mucus, but their walls are slightly moistened with 
serum. 

The formation of pathological secretions takes a different course 
than in mucous membranes. A clear transudation almost without admix- 
ture of formed elements is found in the middle ear, whenever the air is 
shut out for some time (compare occlusion of the tubes with gathering of 
serum). We find on the other hand, when germs of infection are present, 
at first serous or sometimes sero-sanguinolent secretion which soon be- 
comes profuse and purulent, later on, after the most acute stage has 
passed, muco-purulent, and exclusively mucous only towards the end. 
These are different, even reversed conditions from those which we find in 
catarrh of the mucous membranes, where the sputum crudum of the old 
practitioners precedes the sputum coctum. 

The difference of the lining of the middle ear from a mucous mem- 
brane also becomes evident from other facts. There are numerous germs 
of infection constantly present in the mouth, in the entrance of the nose 
and in the pharynx, which become infectious as we suppose only after es- 
pecially harmful influences have gained access, while the drum cavity 
and the other spaces of the middle ear must be considered free from 
germs, according to Zaafal. The penetration of fluid through the tube or 
through a perforation of the drum membrane is sufficient to cause a more 
or less violent exudative inflammation. 



l)Handbuch d. Ohrenheilk. V. Schwartze; Vol. I., page 75. 



132 Division and Nomenclature of Diseases of the Middle Ear. 

Finally in our post-mortem examinations of the ear we find different 
pathologic anatomical changes in the cartilaginous part of the tube from 
those in the bony part. The pharyngeal part of the tube participates in 
the changes of the naso-pharynx which disappear towards the isthmus, 
while, in inflammations of the drum cavity we find the same changes in 
the bony tube as in the drum cavity itself (succulency, injection, etc). 
The cartilaginous tube remains free. The isthmus of the tube forms in a 
certain measure the limit for different forms of diseases which locate on 
either one side or on the other. Diseases of mucous membranes are on 
one side; diseases which are peculiar to serous membranes are on the 
other. 

These are the reasons why the word ''catarrh" for different diseases 
of the spaces of the middle ear complicated matters rather than cleared 
them up, and I shall try therefore to give you a classification of diseases of 
the middle ear which avoids this expression altogether. 

We shall see that just that form of disease whose symptoms even to- 
day are generally considered most characteristic for catarrhal affections 
of the middle ear, I speak of the symptoms of occlusion of the Eustachian 
tube, has really nothing to do with catarrh nor with inflammation. It is 
true that occlusion of the tube may be caused by catarrhal swelling and 
secretion in the cartilaginous tube, but this is only one cause, and, if iso- 
lated, not even a frequent cause of occlusion. 

The changes of the drum membrane and of the function of hearing, 
etc., which are characteristic of uncomplicated occlusion of the tube pure 
and simple, are much more frequently caused by mechanical conditions 
like enlargement of the pharyngeal tonsil, of the rear ends of the turbin- 
als, of the faucial tonsils, etc., or by scars and atresia in the tube. These 
changes are brought on by a physical physiological process which we can 
understand very well, and shall discuss later on. They may exist alone 
for a long time in the ear. 

In classifying the diseases of the middle ear, we must therefore first 
set apart pure uncomplicated occlusion of the tube, as an independent dis- 
ease which may be observed alone without any other disease being pres- 
ent at the same time. We prefer to avoid the expression "catarrh of the 
tubes," which was used up to the present, for reasons that were given 
above. 

There are other inflammatory processes in the middle enr of ex- 
tremely varying intensity, partly in connection with long lasting occlu- 
sion of the tubes, partly independent from it, wh i 'ch are all caused by im- 
migration of germs of infection either from the outside or with the blood. 

A classification of the diseases of the middle ear based on the differ- 
ent species of bacilli and cocci which cause them, can not be carried out, 
because, with the exception of the tubercle bacillus, they all may provoke 
symptoms of inflammation which are quite similar in quality and may 
vary in the same species from the mildest to the most severe. 



Division and Nomenclature of Diseases of the Middle Ear. 133 

The only remaining principle of a classification is the different clini- 
cal and pathologic anatomical appearance. 

We differentiate two main groups, otitis media simplex or non perfo- 
rativa, and otitis media puridenta or suppurativa, or perforative^. In 
the first group there is no perforation and discharge of secretion to the 
outside, in the second, the inflammatory secretions are formed in the 
middle ear have caused a perforation and discharge either through 
the drum membrane or through some other part of the walls of the mid- 
dle ear. 

This establishes a division which can easily be carried out for statis- 
tical purposes, and is at the same time important in the clinical picture of 
the diseases, our prognosis and our therapy, for with the occurrence or 
presence of a perforation all the spaces of the middle ear are accessible 
to new harmful influences from the outside. 

Considering the course of the diseases we subdivide them into otitis 
media simplex acuta, subacuta and otitis media simplex chronica; in /the 
same manner otitis media puridenta acuta, and otitis media puridenta 
chronica. 

We designate as residues of otitis media purulenta with permanent 
perforation those cases in which a suppuration of the middle ear has run 
its course and left a dry perforation; residues with closed opening are 
those, where only a scar is left of a past suppuration. 

There is finally a chronic disease of the sound-conducting apparatus 
in which no secretion is produced. It is characterized by a chronic pro- 
cess in the bony capsule of the labyrinth which leads to fixation of the 
plate of the stapes. This disease was formerly called "dry catarrh of the 
middle ear" and is now named otosclerosis. 

The usefulness of these view-points will be thrown into bold relief 
during the special discussion of the different main groups of diseases of 
the middle ear which are: 

(i) Occlusion of the tubes and its physiological consequences. 

(2) Otitis media simplex acuta and subacuta. 

(3) Otitis media simplex chronica. 

(4) Otitis media purulenta acuta. 

(5) Otitis media purulenta chronica. 

(6) Residues of otitis media purulenta with permanent perfora- 
tion. 

(7) Residues of otitis media purulenta with closed perforation. 

(8) Otosclerosis. 

All the different sequelae as also other pathological phenomena will 
naturally fall into one of these eight main groups. 



134 Statistics and Causes of Occlusion of the Tubes. 

Occlusion of the Tubes. Its Causes in Diseases of the Nose 
and the Naso-Pharynx. Treatment. 

There were 8.2 per cent of all ear patients who suffered from this 
cause of deafness which is subdivided into simple occlusion of the tubes, 
occlusion of the tubes with gathering of serum in the spaces of the middle 
ear, and occlusion of the tubes followed by atrophy of the drum mem- 
brane. 

Children are not represented with nearly as high a percentage in any 
other disease of the middle ear, they amount to 55.7 per cent of all affec- 
tions of the tubes which I observed. My statistics show that children fur- 
nish only 41.4 per cent of the patients with acute suppurations of the mid- 
dle ear, which, as consequences of acute exanthemata of children, are so 
extremely frequent at that period of life. The frequency of affections of 
the tubes in children became very evident in my examination of school 
children; 27.8 per cent of all children who were found to be deaf, 
showed signs on the drum membrane which had to be ascribed to occlu- 
sion of the tubes. 

Later on in life exclusive affections of the tubes become more and 
more rare and in very old people they are observed only exceptionally. 

There is another very interesting fact established by statistics. The 
large majority of affections of the tubes concern both ears (77.0 per cent 
according to my statistical examination). 

We make it our first task to find the causes for occlusion of the tubes, 
and why it is so frequent in the young, and why mostly in both ears. 

There are children who suffer from occlusion of the tubes every time 
they have catarrh of the nose, or angina ; still inspection of the naso-phar- 
ynx does not reveal sufficient explanation for this disposition. We may 
take for granted that the layer of adenoid tissue, contained abundantly 
in the mucous membrane of the cartilaginous tube of children, where in 
some cases it even has a follicular arrangement, (tubal tonsil Gerlach) be- 
came especially well developed. Those children are not necessarily of a 
scrofulous appearance, on the contrary many of them are in blooming 
health. 

We were wrong in suspecting in the adenoid tissue a frequent loca- 
tion of tuberculosis. Systematic examinations of the pharyngeal and fau- 
cial tonsils showed that they comparatively rarely contained nodules. 

It seems however that, besides the very frequent hereditary in- 
fluences, the acute infectious diseases are mainly responsible for the hy- 
perplasia of the adenoid tissue. Besides numerous swollen and reddened 
lymph glands on the neck, the pharyngeal ring of adenoid tissue was al- 
ways found to be more or less thickened and injected in an irregular man- 
ner in all the numerous post-mortems of cases of measles and scarlet 
fever which had just run their course. 

In the large majority of the cases we find positive evidence of a me- 



Adenoid Vegetations. 135 



chanical origin of the occlusion of the tubes in the surroundings of their 
pharyngeal ostium. 

The rhinoscopia posterior and anterior and palpation of the naso- 
pharynx with the finger prove it. 

You know we can survey the naso-pharynx with a small throat mir- 
ror bent at nearly a right angle, inserted behind the soft palate and turned 
upwards. It is accomplished in a similar manner to the inspection of the 
larynx, if we throw light on it with a reflector. Rhinoscopia posterior 
was introduced by Czermak in 1858. Coca'in and a palate-hook have to be 
used whenever contractions of the muscles of the soft palate interfere 
with the examination. 

I use a self-retaining speculum with a spring for rhinoscopia ante- 
rior, shown in fig. 51. It is very light and I have used it for the last 30 
years. 

Palpation of the naso-pharynx is accomplished through the mouth 
with the index finger. A metal finger guard (fig. 52) is slipped over the 
finger to prevent children from biting. 




Y^n. si. 




Fig. 51. Fig. 52. 

Nose-speculum. Finger protector. 

These methods of examination reveal a mechanical obstruction as by 
far the most frequent cause of occlusion of the tubes. The obstructions 
are the hyperplasias of the adenoid tissue in the mucous membrane of 
the naso-pharynx, which at the fornix forms the pharyngeal tonsil, but 
may as well extend over Rosenmiiller's fossae and the openings of the 
tubes. 

Wilhelm Meyer of Kopenhagen was the first to recognize to its full 
extent the frequent occurrence of these hyperplasias in children and their 
bad effect on the ear, whenever they are developed to any extent. 1 IV. 
Meyer found "adenoid vegetations," as they were called by him, in 7.4 
per cent of his patients, which is nearly as high a percentage as I found 
among my patients for all affections of the tubes (8.2 per cent). 130 pa- 
tients of the 175 which Meyer had examined up to the time of his publi- 
cation suffered at the same time from some disease of the ear, and one out 
of every four of the 175, from suppuration of the middle ear. 

The picture which Meyer draws of the general appearance of the 



i Ueber adenoide Vegetationen in der Nasenrachenhole. Arch. f. Ohrenheilk. Vol. 7 and 8, 
1873 and 74. 



136 Adenoid Vegetations. 



youthful possessors of adenoid vegetations is very characteristic. A 
tired, limp expression, caused by the permanent breathing with open 
mouth, develops in the face of these children, making them appear stupid. 
Prolonged mental exertion is really very difficult for them. Guye se- 
lected the expression "aprosexia" later on for this condition, which is not 
exactly appropriate but is now generally accepted. The best explanation 
for the whole condition is the restless sleep constantly interrupted by 
dreams, since the natural mode of breathing through the nose is inter- 
fered with more in the horizontal position and for a greater length of 
time. The children, after the removal of the vegetations by operation, 
sometimes tell us they "can understand and learn much better now." 

Other consequences of constant mouth-breathing are : catarrh of the 
nose, provoked by the gathering of secretions in the nose which by blow- 
ing can be removed only very incompletely or not at all, furthermore ca- 
tarrh of the pharynx, larynx and bronchia which must be attributed to 




Fig. 53. 

Normal nasopharynx as seen in rhinoscopia posterior (according to Semeleder). 

drying of the mucous membranes as well as incomplete cleaning, warm- 
ing and moistening of the respiratory air, functions of the nose which 
cannot be performed because the air does not pass through it. 

Speech also, like respiration, is changed in a characteristic manner. 
The consonants m and n sound very much like b and d. The whole 
speech sounds dull and has no modulation on account of the poor re- 
sounding qualities of the reduced spaces. W. Meyer called this "dead 
pronunciation." 

A large majority of these children suffer also from their ears when- 
ever adenoid vegetations are developed to any extent. Deafness caused 
by temporary occlusion of the tubes is intermittent as a rule and is there- 
fore recognized by parents and teachers only very late, or not at all. 
Such children are considered distracted and inattentive. An examination 
of the drum membrane with the ear speculum shows how long they were 
misjudged. 



Adenoid Vegetations. 137 



In examining the naso-pharynx we are often surprised at the large 
sagittal distance between the soft palate and the rear wall of the pharynx. 
The faucial tonsils too are often more or less hypertrophic. Elevations 
and swellings of adenoid substance appear on the rear and side wall of 
the pharynx, especially on both sides behind the arcus pharyngo palatini. 
The tops of the adenoid vegetations may, in rare cases, become directly 
visible behind the velum. 

We are able to see them to their full extent whenever rhinoscopia 
posterior is possible. In fig. 53 there is a picture of a normal naso-phar- 
ynx according to Semeleder. 

Fig. 54 shows a large hyperplasia of the pharyngeal tonsil and a 
spreading of the adenoid vegetations to both sides over the openings of 
the tubes according to IV. Meyer. 

It is not at all necessary that the adenoid vegetations cover the open- 
ings of the tubes as in fig. 54, in order to effect a closing of the tubes. 
We even find the contrary when we make a rhinoscopic examination in 
cases of affection of the tubes, the opening of the tubes being in reality 
only very exceptionally covered by vegetations. Fig. 55 representing a 




Fig. 54. 
Adenoid vegetations spread over the whole naso-pharynx (according to W. Meyer). 

cut through the pharyngeal tonsil and the tubes according to Ruedinger 
may enlighten you, as to how a large hyperplastic pharyngeal tonsil may 
close up both tubes without over-growing the pharyngeal ostia. The 
picture shows that an enlargement which extends over the whole width 
of the fornix acts like a wedge between both cartilaginous tubes com- 
pressing not so much the opening, as the aperture in the course of the 
tubes, thus interfering with the action of the muscles which ought to open 
them. 

We are justified in diagnosing a real hyperplasia of the pharyngeal 
tonsil only in those cases in which the upper part of the nasal septum 
and the choanae are covered in the rhinoscopic image. 

Large adenoid vegetations may sometimes be recognized through the 



138 



Adenoid Vegetations. 



nasal speculum by means of rhinoscopies anterior. A number of vertical 
bluish-red swellings move in different directions at each act of swallowing 
and reflexes of light shift from one side to the other. 

In palpating through the mouth with a well disinfected finger one 
has the feeling of invading worms on the roof and the rear wall of the 
naso-pharynx. The tissue is usually very soft and brittle, so much so 
that each palpation causes some bleeding. 

The removal of the pharyngeal tonsil becomes necessary whenever 
affections of the tubes either repeatedly recur, or when there is permanent 
breathing through the mouth. The children have to be watched by their 
relatives in order to ascertain whether they snore, or whether or not the 
mouth is open in sleeping, sometimes only to the extent of a narrow slit. 
A small feather must often be held between the lips in order to make sure 

Internal carotid art. 




M. tensor M. levator Hypertrophic Medial car- III Branch of the 

veli palat veli palat phargeal tonsil tilage of the tube fifth cranial nerve 

Fig. 55. 

Frontal section through adenoid vegetations and both cartilaginous tubes, 
(according to Riidinger). 

whether there is really mouth breathing. The operation is indicated 
in mouth breathing even if there are no symptoms from the ear. 

It is not very easy to draw the line between the normal, and a really 
harmful hyperplasia. I think it is one of the greatest merits of Meyer, 
that he determined the numerical frequency of occurrence of adenoid 
vegetations in his statiscal work so accurately, that the careful investi- 
gators of all countries since then obtained similar numbers. It is true 
that others shot beyond the mark. One ear surgeon for example as- 
serted that of all children who consult him he operates in 95 per cent for 
adenoid vegetations. A number of ear surgeons, as soon as the deaf-mute 
institutions opened their doors to them, found there an appallingly large 
number of adenoid vegetations, while my own very extensive examina- 
tions showed that they are not more frequent there than in public schools. 



Adenoid Vegetations. 139 



The removal of the pharyngeal tonsil is an insignificant operation and 
hardly ever followed by important consequences. This fact notwithstand- 
ing, it ought never be performed unnecessarily. The size of the pharyn- 
geal tonsil corresponds to the extension of the naso-pharnyx. Whenever 
the latter is large they are also developed to a considerable size. The 
adenoid tissue shrinks more and more after puberty, as established by 
Meyer. The complete evacuation of a naso-pharynx, which in itself is un- 
usually large, may create a condition whose consequences are more harm- 
ful to the patient than a somewhat hypertrophic pharyngeal tonsil. I 
sometimes noticed the constantly repeating formation of dry crusts in 
noses where the turbinals had been removed by someone else. In a simi- 
lar manner pharyngitis sicca having the characteristic appearance as 
though a coat of varnish had been applied to the walls, may result from 
too radical an evacuation of the naso-pharynx. This condition may sec- 
ondarily extend over the openings of the tubes and in other directions. 
These considerations must be a standard for us in the removal of 
adenoid vegetations and in the selection of our instruments. 

Meyer devised a ring-shaped knife which he introduced through the 
nose and directed it with the finger inserted through the mouth. For- 
merly in the same manner I used a straight snare as fig. 56 shows, armed 
with elastic piano wire. It can be introduced through the narrowest 
nose into the naso-pharynx where the wire, owing to its elasticity, will al- 
ways completely adapt itself to the masses of the tumor. 

It is true the removal in this manner is very sparing, but in order to 
remove all that ought to be removed one has to enter the nose several 
times. 

I have used Gottstein's knife with the modification of Delstanche ex- 
clusively ever since it was invented. It has a flat capsule with hooks for 
the purpose of catching the masses as they are removed. The capsule 
is held against the knife by means of a spring which can be removed for the 
purpose of cleaning. The knife is inserted through the mouth. 

It is a good plan to let the palpation be immediately succeeded by 
the removal as a careful examination with the finger is not much more dis- 
agreeable to the patient than the operation. Palpation either alone or to- 
gether with rhinoscopia will make clear the seat, the size, and the con- 
sistency of the growths. At the same time we may begin to separate the 
brittle masses from the rear wall of the pharynx by means of the finger- 
nail, thus preparing them for the removal. The ring knife is then in- 
troduced behind the soft palate, and pushed up as high as possible along 
the rear end of the nasal septum. The handle is lowered very much in 
order to catch the foremost parts of the growths which are then shaved 
off with one sweep downward from the fornix and the rear wall of the 
naso-pharynx. The curve of the ring knife ought to be so that the cut- 
ting edge points nearly vertically downwards and very little backwards. 
The upper part in a number of recent modifications of this instrument is 



140 



Removal of Adenoid Vegetations. 



bent horizontally backwards. There is no question but that we are able 
with such instruments to extirpate the pharyngeal tonsil much more rad- 
ically, directly from the fibrocartilago basilaris. That however need not 
be our aim, as we mentioned before, since it is sufficient to decapitate 
those hypertrophic parts which protrude over the level, as we do in re- 
moving the faucial tonsils. There is another disadvantage in having the 




y^n. Size. 




Fig. 56. Fig. 57. 

Fig. 56. Straight snare for nose and naso-pharynx. 
Fig. 57. Gottstein's knife with a spring catch according to Delstanche. 

position of the cutting edge more horizontally backwards, — namely it 
shaves the roof of the naso-pharynx very cleanly, but, instead of cutting, it 
scrapes along the rear wall, often getting caught or forming large flaps 
which hang down, and must be removed later on. This annoyance is 
avoided by a more vertical position of the cutting edge. 

The instrument takes effect first along the middle of the rear wall. 



Other Causes for Occlusion of the Tubes. 141 

At a second insertion from high up, down along one side and finally in 
the same manner on the other side, thus removing the lateral remainders 
which are nearest to the tubes. 

Fig. 58 shows two hyperplastic pharyngeal tonsils which were re- 
moved in this manner. 

The after treatment consists in gargles of concentrated solution of 
boric acid with some sodium chloride (20 boric acid to 3 sodium chloride 
to 500 water) to be used every two hours for several days. The patient lies 
on his back and pronounces a long "ga" in order to open the occlusion of 
the palate. A tablespoonful of the same warm solution is poured into the 
nose every two hours and the patient instructed not to blow his nose for 
a quarter of an hour. 

The operation ought not be performed during the acute stage of an 
inflammation of the middle ear. Inflation of air through the tubes ought 
also be avoided for eight or ten days after the operation. I never saw a se- 
rious inflammatory reaction under these conditions. Hemorrhage also re- 




Fig. 58. 

Two hypertrophic pharyngeal tonsils, removed by means of Gottstein-Del- 

stanche's knife. 

mains within moderate limits in using Gottstcin's ring knife. I never 
found that narcosis was necessary. 

Recurrences of occlusion of the tubes become rarer after the removal, 
or stay away altogether. The vegetations may enlarge again later on 
in a few exceptional cases, so that a second removal becomes necessary if 
the operation had to be done in very young children. 

Other causes of constantly recurring affections of the tubes must be 
looked for in a small minority of cases. The rear ends of the lozver tur- 
binals are sometimes so much hypertrophied that their removal becomes 
necessary by means of a snare like the one shown in fig. 56. The enlarged 
faucial tonsils in other cases push up the floor of the pharyngeal ostium 
of the tube to such an extent that they must be removed either on account 
of the crowding of space or on account of the constantly repeating at- 
tacks of inflammation which start from them. 

A number of rare causes of permanent occlusion of the tubes must 
be mentioned. There is the fibrosarcoma of the naso-pharynx occurring 
in youthful age, the rhinosclcroma and other tumors which either start 



142 Other Causes for Occlusion of the Tubes. 

and grow in the naso-pharynx or encroach upon it from the surround- 
ings. 

In one case of long lasting occlusion of the tubes with gathering of 
serum I found at the post-mortem a neuroglioma of Gasser's ganglion 
which extended along the third branch of the trigeminal nerve, compress- 
ing the tube. The poor patient whom I observed many years ago died 
finally of lack of nourishment on account of extreme pains. Today we 
would probably proceed to extirpate the trigeminal ganglion in such a 
case. 

A most frequent cause of recurring occlusion of the tubes in adults 
is the formation of crusts which may extend from the nose to the ostia 
of the tubes. A semi-solid cast of the pharyngeal ostium some time 
after withdrawal is found hanging from the beak of the catheter. It is 
well known that such crusts are in part the consequence of rhinitis atrophi- 
cans with drying, ill-smelling secretions (ozena) in other cases they 
may form in different diseases of the bones of the nose especially of lue- 
tic character. 

Scars after phthisical, tubercular, diphtheritic or varioloid ulcers in 
the naso-pharynx may produce the characteristic phenomena of a high 
degree of retraction of the drum membrane if previous changes in the 
drum cavity did not set in. The ostium pharyngeum may become distorted, 
or constricted, or entirely closed, and on posterier rhinoscopy it can 
hardly be recognized. 

Luetic processes are certainly the most frequent to leave residues 
in the naso-pharynx which we may see rhinoscopically. Hereditary syph- 
ilis also may produce extensive scars in these places. 

It seems that such constrictions and obliterations occur only at the 
pharyngeal entrance to the tubes. Real strictures in its course similar to 
strictures in the urethra do not seem ever to occur (Schwartse "Pathol, 
anatomie"). Furthermore, I could never find them in my numerous post- 
mortem examinations nor in the living. In every case I became con- 
vinced of the fact that as soon as the beak of the catheter has passed the 
stenosis on the pharyngeal ostium, the air easily enters the drum cavity 
in a broad stream, provided there are no pathological changes at the 
other end of the tube. 

I often had a chance to verify on the cadaver that the probe is quite 
an unreliable means to diagnose strictures within the tube, as often even 
on the cadaver it can be pushed only with great difficulty over the angu- 
lar bend which is sometimes found on the limit between the cartilaginous 
and the bony part. 

An occlusion by scars in the course of the tube may be brought 
about through injuries caused by shooting or stabbing. 

As an example I mention a case of atresia of the tube from the scar 
of a stab with a knife which entered through the tragus. 1 A very 



iBerl. klin. Wochenschr. 1883, No. 40. 



Other Causes for Occlusion of the Tubes. 143 



serious hemorrhage after the injury from the mouth, the nose, and 
the ear suggested a small injury of the carotid artery which is close 
to the tube. The case obtained a great forensic interest, in that the patient 
was sued for perjury, because the physician, who was asked by the court 
to examine him, insisted that he was shamming deafness. He went free 
on my statement which was based on the pathognomonic findings of the 
drum-membrane, the hearing tests and the examination with the probe. 

Congenital clefts of the soft and hard palate finally predispose greatly 
to affections of the tubes. The muscles of the tubes are not able to open 
the aperture of the tubes in a normal manner during the act of swallow- 
ing, on account of the divergence of the two halves of the soft palate. 
W. Meyer found furthermore that a considerable hypertrophy of the 
pharyngeal tonsil is usually combined with cleft palate. This explains 
why the phenomena of occlusion of the tubes with all the sequelae which 
we shall discuss later on, are found in the majority of patients with cleft 
palate. 

It was generally taken for granted that a lasting impermeability of 
the nose may produce the same symptoms in the ear as occlusion of the 
tubes. This assumption is apparently supported by the phenomena which 
are produced by the so-called Toyubee's experiment. A movement of 
swallowing is made while the mouth and nose are closed, the latter with 
the fingers. In so doing the air from the nose, the naso-pharynx and the 
spaces of the middle ear is aspirated, causing a feeling of fullness in the 
ear which passes away only after another act of swallowing with open 
nose or direct inflation of air by means of J^alsakus test. Toynbee's 
test is still more successful if the movements of forced inspiration are 
made while the mouth and nose are closed. You can convince yourselves 
by means of the continuous tone series that the power of hearing is con- 
siderably decreased and that hearing of the lowest part of the sound 
scale is entirely lost by air conduction as long as the feeling of fullness 
lasts in the ear. The described effect of aspiration will be continually pro- 
duced at each act of swallowing during every meal, if the nose is perma- 
nently obstructed. It is evident that permanent damage may easily be 
done to the ear. 

Hou'ever, normal power of hearing was repeatedly found in cases 
of congenital occlusion of both choanae. We are therefore forced to 
admit that in the normal condition of the tube an act of balancing of the 
difference of air pressure takes place by means of an action of its muscles 
which is independent of the act of swallowing. This action does not per- 
mit permanent harm to be done to the ear. Consequently we are not 
justified in regarding the impermeability of the nose as a physical cause 
for the development of deafness. 



LECTURE XVI. 

Simple Occlusion of the Tubes and Its 
Physiological Consequences. 

Gentlemen: — The effects of occlusion of the tubes upon the sound 
conducting apparatus and consequently upon the function of hearing 
have a great physiological interest. 

The extensive pneumatic spaces of the middle ear are lined with a very 
delicate membrane containing a system of blood vessels which are ex- 
tended over a large surface. They act similarly to the alveoli of the 
lungs. The oxygen of the air which they contain becomes absorbed 
by the blood vessels and carbonic acid is secreted which has a smaller 
volume. We notice changes of form of the drum membrane which 
prove a rarefaction of the air in the middle ear, as soon as the ventila- 
tion of the spaces of the middle ear, effected normally by each act of 
swallowing, etc., is interfered with by the permanent occlusion of the 
tubes, which are the only avenues for admission of air. The drum mem- 
brane, the membrane of the round window and the lig. annulare of the 
oval window are the only flexible parts of the middle ear, all other walls 
are bone The drum membrane is forced inward whenever the air in the 
middle ear is rarefied and overbalanced by the column of air outside. Its 
form is changed in a characteristic manner which shall soon be described. 

We saw in the physiological discussion of the sound-conducting ap- 
paratus that it is extremely well balanced by two pairs of antagonists, 
namely, the two muscles in the middle ear, and on the other hand, the ra- 
dial and circular layers of fibres of the drum membrane. It is therefore 
fit to fulfill the high requirements which the transmission of weak sound 
waves make upon it. 

You will readily understand that a slight over-balancing of atmos- 
pheric pressure against the outer surface of the drum membrane is suffi- 
cient to interfere with the function of the whole sound-conducting appa- 
ratus. The distance at which whisper is heard may be diminished after 
long lasting occlusion of the tubes from more than 20 meters in the nor- 
mal ear to 10 centimenters and less, i. e., one 200th part of the normal 

144 



The Tympanic Membrane in Occlusion of the Tube. 145 



hearing distance. We are able to improve such hearing at once to the 
normal or nearly so, by a simple inflation of air which balances the pres- 
sure on the outside and inside of the drum membrane, provided there are 
no other changes in the middle ear. This is proof of the fact that the 
deafness in these cases was due exclusively to the overbalancing of the 
apparatus. 

Thus, gentlemen, you can judge of the great diagnostic importance 
of changes of the form of the drum membrane produced by rarefaction 
of the air in the spaces of the middle ear. 

They offer the following characteristics at the examination with the 
ear speculum (compare the plate of pictures of the drum membrane 
no. 2). 

The mobility of the drum membrane is greatest in its center, the 
hammer therefore swings inward on its axis. The handle becomes more 
horizontal and its lower end moves somewhat backward. The lower half 
and the upper anterior quadrant of the drum membrane consequently 
appear somewhat larger to our eye, the rear upper quadrant smaller, and 
the handle of the hammer more or less foreshortened. The short process 
of the hammer which lies closely below and outside of the axis of this 
motion moves downward and outward. It is pressed against the drum 
membrane and thereby becomes more prominent causing several folds to 
form in the membrane. They start from the process and run in different 
directions upward into the otherwise flabby membrana Shrapnelli or 
backward and downward. The last one in the posterior and upper quad- 
rant is the most important. 

It appears as a rather long and clearly illuminated line formed by 
the edge of the fold which may be sharp or dull, starting from the short 
process and running backward and downward toward the periphery, at 
an acute angle with the handle of the hammer. This so-called posterior 
fold 1 may protrude so much that the handle of the hammer which is 
also more horizontal in these cases, may be nearly or entirely covered, and 
the fold may be mistaken, for the handle of the hammer. 

The outer edge and even the rear surface of the handle of the ham- 
mer may become visible through the membrane as w T hitish parts if the 
membrane is pushed inward against the structures in the drum cavity, 
and the whitish neck of the hammer appears under the same circum- 
stances above the short process through the membrana Shrapnelli. The 
long process of the anvil can be seen quite plainly below the posterior 
fold. 

The drum membrane as a whole appears darker, partly on account 
of its being pushed inward, partly on account of the hyperemia ex vacuo 



iWhat we called anterior and posterior liminal strands (page 41) are called by some authors 
anterior and posterior fold. The posterior fold was considered identical with what we call posterior 
fold. However they are not identical, as often can be seen in children suffering from occlusion of the 
tubes. After a successful inflation the posterior fold can still be recognized in its sickle shape, form- 
ing an acute angle with the manubrium mallei, while also from the short process the posterior liminal 
strand runs as a white line upward and backward, in an obtuse angle with the manubrium. The liminal 
strands are strands of connective tissue indicating the limit between the membrana propria and the 
membrana flaccida Shrapnelli. The posterior fold is always pathologic. 

10 



146 The Tympanic Membrane in Occlusion of the Tube. 

in the drum cavity. It contrasts remarkably with the broad, whitish 
streak formed by the handle of the hammer. 

The light reflexes on the drum membrane undergo a number of char- 
acteristic changes. The triangular reflex becomes longer and narrower, 
as long as the membrane retains the shape of a funnel (fig. 59c). The 
form of the funnel changes very easily into that of a flat pan (compare fig. 
59,d) on account of the exclusively one-sided pressure. Consequently the 
triangular reflex and the shining spot in the anterior inferior quadrant 
disappear, since our axis of vision at that spot is not any longer perpen- 
dicular to the membrane as is shown in fig. 59d. The form of a flat pan 
changes into that of a kettle if the pressure from the outside, i. e., the rare- 
faction on the inside, increases still more (compare fig. 59e). A part 
of the concavity of the membrane in the anterior lower quadrant again 




Fig. 59. 

Section through the drum membrane in the axis of the meatus, cutting the 

triangular reflex in half. 

a normal curve, b bulging, c funnel shaped (slight) retraction, d pan shaped (moderate) retraction, 
e kettle shaped (highest degree of retraction). 

becomes perpendicular to the axis of vision and another brightly shining 
reflex is seen, but this reflex has no point and is more or less removed 
from the umbo. It forms a real image of the illuminated surface. The 
peripheral zone of the membrane is usually not subject to the high degree 
of retraction, but forms an edge along which an illuminated line runs in 
a parallel curve to the normal sulcus reflex, called edge reflex. The kettle- 
shaped retracted drum membrane has therefore three reflexes which lie 
close together and give it a very characteristic appearance, whenever the 
sulcus reflex is not covered by the protruding lower anterior wall of 
the meatus (compare on the plate picture no. 2). 

A number of new reflexes may appear around the short process of 
the hammer, namely, reflexes of coves in the retracted membrana Shrap- 
nelli, and in the course of the posterior fold either an illuminated line run- 
ning backward from the short process or, less frequently, a triangular re- 



Other Symptoms of Occlusion of the Tube. 147 

Hex of the rear upper periphery of the drum membrane whose lower limit 
is formed by the fold. 

All these symptoms of retraction are of course rarely found com- 
bined in one membrane. The distinct appearance of a posterior fold, or 
the characteristic removal from the umbo and change of form of the nor- 
mal reflex, combined with a darker color of the membrane are each alone 
sufficient to make the diagnosis of occlusion of the tubes, while on the 
other hand the preservation of the normal bend in the rear upper quad- 
rant of the drum membrane suffices to exclude it. 

The moment we succeed in inflating air through the tube the whole 
picture of the drum membrane changes under our eyes. The abnormal 
light reflexes disappear, the color of the drum membrane becomes clearer, 
the hammer and its short process do not protrude any longer. An indis- 
tinct triangular reflex appears in the umbo and a crescent-shaped reflex 
may even appear on top of a pronounced convexity in the posterior supe- 
rior quadrant. 

The drum membrane may keep this form for a shorter or longer 
time, according to the time it takes the excess of compressed air to flow 
back through the tube. 

Hearing becomes more or less close to normal at the same time that 
the drum membrane obtains its normal convexity. 

Besides deafness the subjective symptoms attending occlusion of the 
tubes are so insignificant, that we usually do not hear the children com- 
plain about them. 

Mouth-breathing, nasal speech and especially the change from deaf- 
ness to normal hearing caused by the temporary spontaneous opening of 
the tubes are characteristic for occlusion of the tubes in children. Adults 
complain furthermore about dullness and fullness in the head, pressure in 
the ear, about subjective noises and increased resounding of their own 
voice. 

It is interesting that the noises, ringing in the ears, etc., disappear 
after inflation, just as suddenly and for the same length of time as the deaf- 
ness. We conclude from this, that the noises do not originate in the 
nervous apparatus but are caused by the increased tension in the sound- 
conducting apparatus. Formerly it was thought that the forcing inward 
of the foot plate of the stapes increased the pressure on the end organs of 
the acoustic nerve. This theory lacks every support since, as we saw be- 
fore (compare page 15) the very yielding membrane of the round win- 
dow is able to move five times as far outward as the stapes can move in- 
ward, and because at least a slow balancing of pressure with the interior 
of the skull takes place through the capillary aquaeducts. On the other 
hand it is very plausible that noises of blood vessels and muscles which 
are normally inaudible are transmitted and perceived much more readily 
through a sound-conducting apparatus whose tension is increased on ac- 
count of one-sided pressure. 



148 Gathering of Serum in the Middle Ear. 

This increased tension of all fibres of the sound-conducting apparatus 
furnishes probably the best explanation for the increased resonance of the 
patient's own voice. Bone conduction to the diseased ear is es- 
pecially increased and prolonged in affection of the tube as is shown by 
its examination with the tuning fork on the vertex. Our own voice being 
partially heard by bone conduction acts like the tuning fork. This reso- 
nance of the voice disappears every time after inflation of air. It must 
not be confused with real tympanophonia which we shall become ac- 
quainted with in the chapter on "permanently open tube." 

Direct Consequences of Occlusion of the Tubes. 

Gentlemen : — The gathering of serum in the spaces of the middle 
ear is a consequence which hardly ever is lacking after prolonged occlu- 
sion of the tubes. A transudation takes place from the enlarged vessels 
of the lining of the middle ear on account of the prolonged rarefaction 
of air. Large quantities of an amber colored, transparent fluid are dis- 
charged if the paracentesis of the drum membrane is followed by an in- 
flation of air. This fluid may become viscid if it stays in the middle ear 
for some time, but will always remain transparent as long as no inflam- 
mations intercur. 

Scheibe and Brieger always found this fluid free from germs, which 
fact is of great value for the separation of affections of the tubes from in- 
flammatory diseases of the middle ear. It is therefore not an inflamma- 
tory exudation but a simple transudation caused mechanically by rarefac- 
tion of air and consequent hyperemia ex vacuo. This fluid is not under 
increased but diminished air pressure; and on making a paracentesis we 
may often see an air bubble arising on the inside of the drum membrane 
from the opening of the paracentesis. The transudation is often spread 
in great quantities over the extensive spaces of the middle ear, and can be 
evacuated into the external meatus only under the condition that the para- 
centesis is succeeded by inflation of air. 

The fluid which gathers in the tympanic cavity can often be seen 
through the drum membrane before the paracentesis. It apears as a 
greenish discoloration of the lower periphery or of the lower half of the 
membrane which is divided by sharp, dark, upward concave lines from 
the upper dark gray half. A posterior and an anterior concave line is 
sometimes found which meet in a point at the handle of the hammer. 
This picture is caused by two air bubbles, one of which adheres to the an- 
terior, the other to the posterior superior quadrant of the drum membrane. 
A number of smaller air bubbles may be seen sometimes after inflation 
through an especially transparent drum membrane. 

The subjective symptoms are especially characteristic. Deafness 
varies much more than in simple occlusion of the tubes. It changes even 
in a change of position of the body, becoming less while reclining, when 
the fluid runs back into the cells of the mastoid process. It is not very 



Collapse of the Tympanic Membrane. 149 

rare to have patients say that water moves to and fro in their ear, when- 
ever they move their head. In fact in moving the head we can often see 
the lines of fluid, like those of a water level, moving back and forth. 

The so-called collapse of the drum membrane must be mentioned as 
a consequence of long persisting occlusion of the tubes which manifests 
itself later on. The atmospheric pressure weighing on its outer surface 
causes gradual stretching and atrophy of its fibres which either may be 
limited to certain parts of the drum membrane, especially the posterior 
superior quadrant (compare the plate, picture 3 and 4) or may extend 
over the whole of it (picture 5). 

The thin transparent membrane in the latter case clings like a wet 
garment to the structures in the tympanum. The handle of the hammer, 
the joint between the incus and stapes, sometimes also the promontory 
protrude as in relief. A number of new reflexes may be noticed not 
alone in the anterior, but also in the posterior half of the membrane 
around the joint between the incus and stapes and on the promontory. It 
sometimes seems as though the whole drum cavity lay bare and only the 
handle of the hammer was in its place. Only by means of Siegle's oto- 
scope or inflation of air can we convince ourselves of the presence of the 
drum membrane. 

Siegle's pneumatic ear speculum is closed at the top by an oblique 
glass plate or lens, and is connected on the side with a rubber tube. The 
movements of the drum membrane can be watched through it if the air 
in the tube is rarefied and compressed after the speculum is inserted 
hermetically into the meatus. 

The structures in the tympanum disappear from view after inflation 
of air through the catheter or by means of Politzcr's method and the 
drum membrane bulges into the meatus forming folds similar to the 
flower of convolvulus (compare on the plate figure 4). 

The pronounced forms of collapse of the drum membrane develop 
only after occlusion of the tubes has existed for many years or recurs 
persistently. Therefore they are found just as frequently in adults as in 
children. They may continue for decades without further consequences, 
although exceptionally. 

Atrophy is often confined to some spots on the rear upper quadrant 
of the drum membrane, which are deeply retracted over the joint between 
the incus and stapes and over the tendon of the stapedius muscle, all pro- 
truding in relief. It is very remarkable that in these cases the long pro- 
cess of the incus is often missing, and the head of the stapes together with 
its tendon are there alone (compare on the plate fig. 5). The reason for 
this finding is the fact that sometimes the incus is luxated backward on 
account of the horizontal position of the hammer, occurring, as we saw, 
not infrequently in retraction of the membrane ; at other times it is lost 
or destroyed by preceding intercurrent inflammations. The posterior 
upper quadrant protrudes like an irregular blister over the drum mem- 



150 The Treatment of Occlusion of the Tubes. 

brane after inflation (compare the plate fig. 4). This picture may also be 
seen when the patient, by blowing his nose shortly before the examination, 
succeeded in forcing air into the middle ear. 

The changes of form in collapse of the drum membrane, whenever 
they are well developed, will persist even after occlusion of the tubes has 
ceased and they have become quite patulous. 

The power of hearing in the cases of uncomplicated occlusion of the 
tubes and in those with gathering of serum can usually be restored to its 
full extent by treatment, while in those with pronounced collapse more 
or less of it is generally lost. It may become very close to normal, when 
the tube has become patulous again. Such cases show that the diminu- 
tion of hearing does not depend upon the change of the form of the drum 
membrane in the first place, but upon the one-sided over-balancing of 
pressure. 

The great number of different sequelae which may occur in the ear, 
besides the two which were described here as consequences of occlusion of 
the tubes, are of inflammatory nature and will be discussed in later chap- 
ters. We shall see there more clearly how important a very careful study 
and knowledge of the clinical picture of pure occlusion of the tubes, as I 
have given it here, is for our comprehension of the development of the 
different diseases of the middle ear and for our whole diagnosis. 

Treatment of Occlusion of the Tubes and of Its 
Consequences. 

The first requirement in treating occlusion of the tubes and its se- 
quelae is to make the tubes patulous and keep them patulous as often as 
occlusion recurs. Politzer's method generally accomplishes this in chil- 
dren. It consists as you know of inflating air through a canula inserted 
into the entrance of the nose, while at the same time both openings of the 
nose are hermetically closed over it with thumb and index finger, and the 
mouth is shut off from the naso-pharnyx by the raising of the soft palate 
through the act of swallowing or crying. 

Politzer uses for inflation a simple pear-shaped rubber bulb. We pre- 
fer Lucae's double bulb for performing Politzer's method and catheteri- 
zation, since it produces a longer lasting current of compressed air. A 
wide dull glass tube (compare fig. 15 page 30) is used to connect the 
rubber tube with the nose. 

Small children, who cannot be induced to swallow when ordered to 
do so, are layed on their back and a teaspoonful of water is poured into 
their mouth the moment everything is ready for the inflation. 

The success of Politzer's method is recognized by the distinctively 
visible changes of the drum-membrane and by comparing the hearing be- 
fore and after inflation. 

Too much pressure must not be used if some spots or the whole 



The Treatment of Occlusion of the Tubes. 151 

drum membrane show the symptoms of collapse, or if there is a thin scar, 
since a thin part may rupture through too high pressure. 

A valve-like occlusion of the pharyngeal ostium of the tube which 
cannot be overcome by means of Politzer's method seems to occur in some 
patients, children as well as adults. In such cases we have to use the 
catheter for inflation, even in children. The insertion even at that age 
does not offer any difficulties to any one who is used to it. The air enters 
into the middle ear with a strikingly uneven, rugged noise as soon as the 
catheter has passed the obstruction which is usually at the pharyngeal os- 
tium of the tube. 

It is sufficient to repeat the inflations every 2 to 3 days, even if 
the hearing distance should recede earlier than this period. 

We use inflation first in the cases in which serum has gathered. 
The transudation may stop and absorption may begin by establishing 
normal pressure in the middle ear. It is well, in order to evacuate fluid 
which is present in the middle ear, to have the head in catheterizing in 
such a position that the tube points perpendicularly downward, that is 
the head of the patient must be inclined towards the good ear, downward 
and forward. 

The serum must be evacuated through a paracentesis in the drum 
membrane whenever a large amount has gathered and the occlusion of 
the tubes has lasted for some time. The small operation is in these cases 
little or not at all painful. 

In order to do it antiseptically the meatus is injected with a warm 
three per cent solution of carbolic acid, afterwards the meatus and the 
drum membrane are cleaned and dried with a probe wrapped with cotton. 
The paracentesis is made with a lance-shaped knife 1 to 2 millimeters in 
width (compare fig. 45 page 107) in the rear lower quadrant of the drum 
membrane and parallel with the handle of the hammer. 

It must not be forgotten that the bulb of the jugular vein sometimes 
lies bare at the floor of the tympanic cavity or even protrudes into it. A 
number of injuries to it have been reported in literature; one of which 
terminated fatally because pyemia had set in. The carotid artery also 
may be found lying bare on the anterior wall of the tympanic cavity in ex- 
ceptional cases. For these reasons sickle knives ought not be used for 
paracentesis. 

An air bubble as before stated frequently rises on the inside of the 
drum membrane the moment the lance penetrates into it, proof of the 
existing rarefaction of air, which also prevents a spontaneous discharge 
of the fluid outward. 

An astonishingly large quantity of amber colored fluid can some- 
times be forced into the external canal by means of Politzer's method. 
It seems to be more expedient to drain it in the reversed manner through 
the tube. We give the head the above-described position for this purpose, 
the tube directed vertically downward, then, by compressing the double 



152 The Treatment of Occlusion of the Tubes. 

bulb whose canula has been hermetically inserted into the meatus, we force 
the air through the opening in the drum membrane during the act of 
swallowing. 

A deep bubbling noise originates in the naso-pharynx caused by the 
fluttering to and fro of the membranous walls of the tubes and on in- 
spection the drum cavity is found empty. Pressure must not be too high 
in this external inflation of air, as considerable dizziness may result, 
probably from intense commotion of the membrane of the round window. 
Infection from germs thrown into the middle ear from the naso-pharynx 
can safely be avoided by external inflation. 

I usually inflate some boric acid powder against the drum membrane 
after removal of the serum, partly as a protection from infection from the 
outside, partly in order to remove the last remnants of serum by the capil- 
lary attraction of the little flat crystals of boric acid. We find the pow- 
der usually colored yellow like honey the next day. 

The opening in the drum membrane is usually healed after 2 to 3 
days in uncomplicated cases when also normal hearing is obtained which 
remains if the occlusion of the tubes itself is amenable to treatment. 

The opening in an atrophic membrane may remain open for a longer 
period of time. 

Paracentesis or better even cutting a large hole in the drum mem- 
brane are often the only means to improve hearing at least temporarily 
in atresia of the tube by scars or by tumors which cannot be removed. 
Hearing may remain improved for weeks after a simple paracentesis as 
the membrane is usually atrophic under such conditions. 

It is very difficult to make a permanent opening in the drum mem- 
brane on account of its great faculty of regeneration. 

Paracentesis in gathering of serum may be recommended to the 
patients without hesitation as I never saw it followed by suppuration if 
the precautions which I have described are taken. This fact which was 
established by many years of observation is important to us for two other 
reasons. 

Firstly, it furnishes a new proof for the fact that the serum which 
has gathered on account of occlusion of the tube is always free from 
germs as bacteriological examinations have shown before. 

Secondly, it shows that under normal conditions germs of infection 
cannot be transmitted to the middle ear through the tube in perforations 
of the drum membrane. Suppuration never occurred after paracentesis 
even when Politzer's method through the nose instead of external inflation 
was used. We shall return to this subject in speaking about acute inflam- 
mations of the middle ear, and shall see of what importance the results 
of the above mentioned observations are for our judgment of these patho- 
logical processes. 

We have finally to say a few words concerning the therapy of dis- 
eases of the surroundings which may lead to occlusion of the tubes. We 



The Treatment of Occlusion of the Tubes. 



153 



have already discussed the operative removal of adenoid vegetations, and. 
wherever it appears necessary, of the faucial tonsils, also of the posterior 
ends of the lower turbinated bodies. Our attention must be given to the 
removal of crusts and tenacious masses of secretions which gather in the 
nose and naso-pharynx, often obstructing the entrance of the tubes or oc- 
casioning its agglutination. 

The crusts in ozena may be removed from the nose by three differ- 
ent methods. 

The best known method is Weber's nasal douche which most general 
practioners use. A considerable quantity of fluid 
is conducted into one nostril by means of a siphon 
or an irrigator and is drained through the other 
nostril. It is not so well known however that this 
manipulation, which was intended to remove dam- 
aging obstacles from the surroundings of the ear, 
may do great harm to the ear itself if carelessly 
applied. The otologist has occasion often enough 
to see inflammations of the ear after nasal douches 
or simple pouring of water into the nostrils on ac- 
count of the general application of this mode of 
cleaning the nose even by laymen. Profuse sup- 
purations with perforation of the drum membrane 
and a number of further deleterious sequelae are not 
infrequent. The beginning of the disease of the 
ear is usually distinctly attributed to the nasal 
douche by the patients. They felt the fluid suddenly 
entering the ear while washing, and from this 
moment their trouble began, first a feeling of full- 
ness, later on pain in the ear and increasing deaf- 
ness. 

The connection can well be understood. The 
tube is closed in repose. The moment it is opened 
by an action of the muscles of the palate and tubes during the douche 
the fluid enters into the spaces of the middle ear and carries there all 
the germs of decomposition which it gathered on the road. 

This danger to the ear can be avoided if the patient does not swallow 
or speak during application of the douche. A half liter (about one pint) 
of luke warm solution of boric acid or a weak salt solution is used. The 
irrigator must not be raised more than 80 centimeters (about 2.y 2 feet). 
The canula must be inserted horizontally into the nostril which is least 
open. The patient must be warned not to close the other nostril with his 
finger. The fluid must then be expelled by exhaling forcibly, keeping 
the nose open, and for a quarter of an hour blowing the nose with the 
handkerchief ought to be avoided. 

Atomizers with long straight tubes or bent tubes with holes on the 
side for the pharynx are less dangerous than Weber's nasal douche. 




Fig. 60. 

Probe for the naso 
pharynx. 



154 A Perpetually Open Tube. 

Gottstein described a very suitable method for removing crusts from 
the nose. A large pledget of cotton is inserted high up into the middle 
nasal duct. The cotton is wrapped around a straight probe about the thick- 
ness of a match, for a distance of 4 to 5 centimeters. After insertion the 
probe is pulled out, while the cotton is retained with two fingers. The cot- 
ton irritates the nose like a foreign body, and the walls produce sufficient 
fluid secretions to loosen the hard crusts, which are usually blown out to- 
gether with the cotton when we see the patient again the next day. In 
case some pieces still remain adherent they can be removed by means of 
Weber's douche or the atomizer. Ozena can be influenced symptomati- 
cally by Gottstein' s tamponade at least to such an extent that the bad smell 
disappears. 

Tenacious, tightly adherent and dry masses in the naso-pharynx can 
only be removed mechanically by means of a thick bent probe without 
probe end (compare fig. 60) which is tightly wrapped with cotton for a 
distance of 2 to 3 centimeters, and is inserted behind the soft palate 
through the mouth. 

Perpetual Opening of the Tube. 

The aperture of the tube may permanently remain open on account 
of changes in its surroundings. This is a comparatively rare occurrence. 
The few patients whom I examined while showing the characteristic 
symptoms of permanently open tube, presented, without exception, the pic- 
ture of great general emaciation produced in a short time by phthisis in 
the last stages or other serious general diseases or senile marasmus. A 
thick layer of fat surrounds the cartilaginous tube, according to Riidin- 
ger. Atrophy of this layer causes the external membranous wall to be- 
come detached from the inner cartilaginous wall and the aperture of the 
tube to gape. 

An extremely disagreeable resounding of their own voice forces the 
patients to consult the otolgist. The "tympanophonia" which thus arises 
is much greater than resonance caused by increase of bone conduction 
which we mentioned in connection with occlusion of the tubes. It is 
produced when sounds formed in the mouth and pharynx enter directly 
into the tympanic cavity through the open tube. Whoever like myself, is 
able to open his tube at will and keep it open can easily convince himself 
of the change and increase in strength of his voice. It appears indistinct 
in spite of the powerful rumbling noise accompanied by over tones of 
highest pitch, and we experience a disagreeable sensation of trembling of 
the drum membrane. Even simple inspirations and expirations sound 
like loud noises. I was often able to observe changes of the reflexes on 
the tympanic membrane which occurred with each inspiration and expi- 
ration during forced respiration in patients with open tubes. 

Hearing itself is not materially diminished in patients with open 
tubes. 



A Perpetually Open Tube. 155 

The above-described clinical picture gives us an insight into the use- 
fulness of the normal mechanism of the tubes and its faculty of momen- 
tary opening. There is another reason why I mentioned it here, namely, 
because we have a very simple procedure to give patients at least tempor- 
ary relief from their annoying affliction. I use an insufflation through the 
catheter of salicylic and boric acid powder one part in four for this pur- 
pose. Tympanophonia disappears instantly and often stays away for a 
number of days on account of the irritation of the mucous membranes and 
the increased secretion. 

Injuries and foreign bodies in the tubes are such rare occurrences 
that I can refer you to the monograph of Passow on ''Injuries of the 
organ of hearing." 



LECTURE XVII. 

Acute Inflammations of the Middle Ear. 

Etiology. 

Gentlemen : — The affections of the tubes which have so far been dis- 
cussed have purely mechanical issues. The inflammatory processes in the 
middle ear which we now have to consider are of different character. The 
presence of organized germs of infection has been established with such 
regularity that we can not doubt of their causative importance as to the 
pathogenesis of all inflammations of the middle ear. The numerous bac- 
teriological examinations made since ZanfaVs initiative showed that 
germs were never absent in the slight cases which do not perfor- 
ate, as well as in the serious perforating forms of inflammations. 

Zanfal and later investigators only exceptionally succeeded in raising 
cultures of some few germs from the normal drum-cavity. We are justi- 
fied in the supposition that so small a quantity of germs are powerless 
against the living cells of the normal lining of the middle ear. We also 
found the transudations formed ex vacuo in the middle ear after pro- 
longed occlusion of the tubes, to be free of germs. The exudations which 
form while symptoms of inflammation are present and which always con- 
tain more or less cells, on the contrary are regularly impregnated with 
one or more forms of pathogenic micro-organisms. 

Diplococcus pneumoniae and streptococcus pyogenes are found the 
most frequently. The different forms of staphylococcus pyogenes usually 
appear secondarily after a suppuration has lasted for a while, although 
sometimes they seemed to be the primary infection. A number of other 
micro-organisms were found in some few cases. Even the germs which 
usually cause some general acute infectious disease like influenza, typhoid, 
diphtheria bacillus and meningococcus intracellularis were found in the 
purulent secretions of the middle ear. 

We might expect in each inflammation of the middle ear occurring 
in the course of some general infectious disease, to find simply the specific 
organism in the secretions. Conditions are however not so simple. There 
were on the contrary only few cases in which the specific germs of the 

156 



Etiology of Acute Inflammations of the Middle Ear. 157 



general infection were shown also in the middle ear, and even then very 
rarely in pure cultures. The general pyogenic organisms, strepto, diplo, 
and staphylococci were found either exclusively or in by far the greater 
number. 

Von Trocltsch established the fact that inflammatory changes with 
gathering of secretion in the middle ear are found in nearly every post- 
mortem examination of infants of the first few years. It seems therefore 
that the middle ear at that age becomes affected in nearly every general 
disease. Prey sing published a very careful investigation of ioo post- 
mortem examinations of children less than 3 years old. He found patho- 
logic changes in the middle ear in 81 per cent, and of all positive bacterio- 
logic findings pneumococcus was shown in 92 per cent. 

Streptococci were found by far the most frequently in the secretions 
of otitis complicating acute infectious diseases like scarlet fever, measles, 
etc. They were also found in nearly every case where serious complica- 
tions implicating the blood vessels or the brain developed after an otitis. 
The presence of streptococci became evident in every case of thrombo- 
phlebitis which was examined in my ambulatory clinic. Pneumococci 
were found on the other hand in genuine uncomplicated otitis, in empyema 
of the mastoid process and in the local extensions to its surroundings. 

The impression may be gained from this rudimentary synopsis of 
the bacteriological findings in the middle ear to which we have to confine 
ourselves, that the kind of bacteria wdiich develop, as w T ell as the mode of 
their propagation and spreading, are dependent to a certain degree upon 
the soil on which they grow. The adult organism considered in opposition 
to the infantile organism, as well as general infectious diseases, produce 
changes in this soil which favor the growth of certain bacteria. 

It would be shortsighted to consider an occurrence like this which re- 
peats itself in all diseases of the first few years and in the most frequent 
acute infectious diseases like measles, scarlet fever, etc., with such regular- 
ity as simply abnormal and harmful to the organism. 

The formation of an exudation rich in cells, formed under such cir- 
cumstances in the middle ear, may possibly be compared to the abundant 
emigration of leucocytes which we can observe in the lymphatic ring in 
the pharynx, or (in examining fresh nasal polypi), through the interstitia 
of the ciliated cells, and which we may suppose takes place also in 
Peycr's and the solitary glands of the bowels. A transportation outward 
of toxines and products of decomposition of some, maybe partially still 
unknown micro-organisms of infectious diseases, may possibly take place 
during the increase and spreading of the normal process of emigration of 
leucocytes to the surface which perhaps is a necessary link in the course of 
healing of those infectious diseases. 

The constant presence of pyogenic micro-organisms in the mouth and 
pharynx of healthy persons, and even the few germs that were found in 
the normal tympanum might find their place in the following train of 



158 Pathogenesis of Acute Inflammations of the Middle Ear. 

thought : we might see in them or in their increase at each pathologic alter- 
ation of the walls, factors which produce irritation inducing an increased 
emigration of leucocytes charged with morbid matter. 

I can not refrain from at least hinting at my merely hypothetical ideas 
concerning this dark domain. They enlighten a number of facts estab- 
lished by observation, which so far were entirely beyond our comprehen- 
sion, from a view point that makes those facts appear suitable for the 
general economy of the organism. 

We have become acquainted with a number of causative features for 
the pathogenesis of acute and subacute inflammations of the middle ear 
through our clinical experience. 

It is very easy to understand that an inflammation of the tympanum 
may set in after direct injuries to the drum membrane if for example the 
perforation was caused accidentally by pushing in an infected instru- 
ment, or if, in an indirect rupture of the membrane, an injection was made 
through the meatus which always contains pathogenic germs. 

The etiological process is the same if fluid enters the drum cavity 
through the tube, as we see it often in nasal douches. 

The observation made on a conductor suffering from diabetes may 
be mentioned here as an instructive example. Tortured by thirst he held 
his mouth directly under a water pipe and felt the water as it ran through 
his nose into the ear which was directed downward. A serious inflamma- 
tion of the middle ear, with perforation of the drum membrane and pro- 
fuse suppuration lasting for weeks, developed as a direct sequence. 

Suppurations of the middle ear often start after baths. They are 
produced when water which enters into the pharyngeal ostium of the tube 
in plunging, is afterwards forced into the middle ear by blowing. In many 
cases there is an old perforation of the drum membrane. 

Similar experiences show how easily watery fluids may pass through 
the tube, which by its form however, is protected from the entrance of 
normal secretions from the nose into its cartilaginous part. We can easily 
imagine that tenacious secretions which may have gathered there are 
ejected from the funnel-shaped entrance to the tube by any strong cur- 
rent of air which strikes against it. Under no circumstances can such se- 
cretions be forced higher up than the beginning of the slit-shaped part of 
the cartilaginous tube, the walls of which touch during repose. The 
movements of the ciliated epithelium of the tube are directed towards the 
pharyngeal ostium and will remove small particles, pathogenic germs, etc. 

Injections of fluid into the middle ear through the catheter which 
were formery frequently used for therapeutical purposes are fortunately 
being more and more abandoned, as their harmful influence was suffi- 
ciently shown by the statistics of some authors. 

Acute and subacute inflammations of the middle ear from the slight- 
est to the severest perforative types are furthermore a frequent concomi- 
tant of acute catarrhs of the nose and pharynx as also of acute angina. 



Pathogenesis of Acute Inflammations of the Middle Ear. 159 

The changes of the mucous membrane progress through the tube to the 
middle ear, just as they do to other cavities of the nose, to the larynx 
and bronchi. 

Artificial inflammations in the nose and pharynx as they are produced 
for example by galvano cautery advance with comparative frequency to 
the middle ear. 

Violent otitis was often observed after tamponing the naso- pharynx 
which is caused perhaps by the extensive harm done to the ciliated epithe- 
lium. 

Prolonged and recurring occlusions of the tubes, as clinical observa- 
tion shows, are an extremely frequent cause for the onset of inflammatory 
processes with exudations in the middle ear. We became acquainted with 
their primary mechanical consequences in the last chapter. We shall see 
that it is easy to separate the cases with pure transudations from those in 
which inflammatory processes have set in. 

We have no clear conception and can only pronounce suppositions as 
to the relation between the occlusion of the tube and the immigration or 
quick propagation of germs in the middle ear. The latter we must admit 
is a condition for the development of inflammatory exudative processes. 
Occlusion of the tubes will hardly interfere more than the normal tube 
with the propagation of inflammatory processes in their continuity or 
with immigration of germs. This does not explain why it occurs more 
frequently than in the normal. 

The immigration is perhaps favored by the damage done to the cil- 
iated epithelial surface especially as acute catarrhs are very frequent when 
adenoid vegetations are present. 

It is possible also that, in a sudden piercing of the occlusion by ab- 
normally high pressure of air, larger particles may be hurled through the 
tube, (the epithelium being probably partially defective) than would be 
possible through a normal tube which opens easily and has intact ciliated 
epithelium. 

May this connection be as it will, the great importance of occlusion 
of the tubes for the development of otitis is proven by daily experience 
with our patients. 

It must remain an open question whether or not "catching cold" 
which is mentioned in the otological statistics as one of the most frequent 
etiological factors plays really so important a part among the causes of 
inflammations of the middle ear either with intact or occluded tube. How 
careful we must be in accepting this etiology which is advanced especially 
by patients of the better classes, is shown by the fact that deafness caused 
by ear wax is also attributed to catching cold just about as frequently 
as inflammations of the middle ear. Even in plain view of large masses 
of ear wax removed from the ear we often hear the question: "So I 
must have caught a cold anyway?" It is therefore better that we desist 
from giving an etiological explanation of those rather numerous cases of 



160 Otitis Media Simplex Acuta. 

genuine otitis for which we can find no other cause than to base our sta- 
tistics on such unreliable statements of the patients. 

We shall see in the chapter on suppurations of the middle ear how 
often each of the different acute exanthemata and each of the other acute 
infectious diseases is complicated by inflammatory processes in the middle 
ear. These diseases of the ear differ as to their seriousness and in many 
other regards from the genuine forms. Their clinical picture is mostly 
that of acute suppurative otitis media with more or less extensive de- 
struction of the drum membrane. Systematic examination of the ears in 
post-mortems after different infectious diseases showed that the partici- 
pation of the ear is much more frequent than was supposed from ex- 
perience on the living, and that all the different degrees occur, from the 
slightest exudative processes of inflammation which are absolutely latent 
to clinical observation, because they are too insignificant to cause a per- 
foration of the drum membrane, up to the gravest perforative forms with 
the most extensive decomposition and necrosis of the walls and contents 
of the middle ear. 

It is well for the above stated reasons to distinguish between otitis 
with perforation and otitis without perforation, in spite of the fact that 
the same micro-organisms may produce the most diverse degrees of inten- 
sity of inflammation of the middle ear and that there is a continuous transi- 
tion from the slightest to the most serious forms, which can especially be 
established by pathologic anatomical examinations. This distinction more- 
over does not offer any difficulties for our statistical studies. 

Acute and Subacute Simple Inflammation of the Middle Ear 

Without Perforation of the Drum-Membrane. Otitis 

Media Simplex Acuta and Subacuta. 

Otitis media simplex acuta and subacuta differ from each other only 
in their intensity and in the duration of the clinical symptoms. 

8.9 per cent of all ear patients suffered from these diseases, according 
to my statistics. This is nearly the same percentage as that of affections 
of the tubes which is 8.2 per cent. 

Children are, however, represented in the latter disease by 55.7 per 
cent, while in acute and subacute otitis media simplex only 22.5 per cent 
are children. 

There is also a difference in the answer to the question whether one 
or both ears are affected, inasmuch as 77 per cent of affections of the 
tubes concern both ears while only in 31.1 per cent of cases of otitis media 
simplex acuta and subacuta both ears were affected at the same time. 

The difference in the numbers just mentioned may be taken as proof 
of the fact that in the development of inflammatory diseases of the middle 
ear other causes than a pre-existing occlusion of the tubes must be active. 

Otitis media simplex acuta shows the four cardinal symptoms which 
are characteristic of inflammations in general, namely, tumor, rubor, 
calor, dolor. 



Otitis Media Simplex Acuta. 161 

The clinical picture is often blurred by some serious general disease 
or by other causes which I have already enumerated. Whenever this is not 
the case the main subjective symptom is pain in the ear which is more or 
less severe, often spreading over the whole side of the head, starting 
mostly at night in the course of a catarrh, or influenza or even in the other- 
wise healthy organism. These pains increase in coughing, blowing the 
nose, swallowing, and especially when air enters the middle ear in belch- 
ing. Pulsating noises and a very disagreeable feeling of fullness and pres- 
sure are felt at the same time. 

We find on examination the next morning bright red injection of the 
vessels of the drum membrane along the handle of the hammer and of 
the radial vessels of the periphery. The redness may also be more dif- 
fuse, locating on the rear upper quadrant or spreading over the entire 
drum membrane. It is not unusual, especially in influenza, to find differ- 
ent sized, recent extravasations of blood along the handle of the hammer 
or on other spots of the surface. 

The temperature may rise in the beginning to a high degree espe- 
cially in children, although this does not mean that a perforation of the 
drum membrane is liable to occur. 

There is a swelling of the cutis from the formation of an exudation 
which makes the drum membrane appear flatter, the handle of the hammer 
becoming indistinct. 

The infiltration and redness may extend over the limits of the drum 
membrane to the cutis of the posterior upper wall of the meatus which is 
normally somewhat thicker than the remainder. This is the reason why 
the limits of the membrane on this part are often effaced or have disap- 
peared entirely. Serous, or, especially in influenza, hemorrhagic blisters 
may form on the surface of the drum membrane if the exudation increases 
and may spread over the walls of the meatus. 

Hearing may be comparatively good during the first day, although 
the phenomena of inflammation on the drum membrane may be very 
pronounced. Whisper may be heard at a distance of several meters. It 
decreases considerably during the next few days, although the symptoms 
of inflammation at the membrane diminish, yet it does not sink below 
10 centimeters as a rule in a formerly normal ear. 

Coincident with the progress of the disease the symptoms of gather- 
ing of secretions inside the drum membrane become evident. The 
membrane, especially its rear upper quadrant, bulges, which may be recog- 
nized partly from the more pronounced convexity of radial blood vessels 
and partly from the development of a crescent-shaped indistinct reflex 
appearing along the rear upper periphery. The epidermis of the drum 
membrane in extremely acute exudations may become infiltrated and torn, 
when some secretions may penetrate into the meatus for a very short 
while, yet no perforation exists. 

Bulging of the drum membrane especially of its posterior superior 
11 



162 Otitis Media Simplex Acuta. 

quadrant is never absent in the beginning of the inflammation, even when 
the inflammation developed on the basis of an affection of the tubes, in 
fact it is as a rule even more pronounced and characteristic in these cases 
because some of the fibres of the drum membrane have previously under- 
gone a certain amount of stretching. Later on when the acute inflamma- 
tory symptoms have ceased the characteristic retraction of the membrane 
connected with occlusion of the tube gradually replaces the bulging. 

The functional tests bring forth many characteristic points for otitis 
media acuta and also subacuta. We can consider that the peculiarities 
which we find here depend upon the gathering of exudate in the sur- 
roundings of the sound conducting apparatus and upon the infiltration of 
its soft parts. 

We find the same functional phenomena in acute perforative diseases. 

Disturbances of function which are characteristic for the other dis- 
eases of the sound-conducting apparatus (fixations and defects) show 
striking modifications in exudative processes in the tympanum. Bone 
conduction is prolonged even to a considerable degree. Accordingly the 
tuning fork placed on the vertex sounds in the diseased ear. We do not 
obtain such decided and unvarying statements concerning the result of 
Weber's test in any other disease of the sound-conducting apparatus. 
However hearing of the lower end of the sound scale by air conduction is 
only slightly interfered with, sometimes apparently not at all, since the pa- 
tient often hears sounds as low as 16 v. d. by air conduction. Rinne's test 
also is not by any means always negative but may be positive, though 
shortened, in spite of a considerable diminution of hearing for whisper 
(down to 10 centimeters). 

The explanation for this varying functional attitude of the processes 
of exudation compared to fixations and defects of the sound-conducting 
apparatus must be sought in the fact that there is no fixation present, only 
an increased encumbrance of this apparatus with fluid. 

The prolongation of bone conduction is effected here in a different 
manner than in fixation of the apparatus. The chain of ossicles instead of 
being fixed is only overloaded. It can therefore but incompletely follow 
the vibrations caused throughout the head by the tuning fork on the ver- 
tex on account of its increased weight and therefore increased momentum. 
Greater countermovements are thus caused in the chain than is normally 
the case in the unbalasted chain, which acts as a mass suspended freely 
movable in the drum cavity. 

Hearing by air conduction may be little interfered with as far as pure 
sounds with their regular and steady vibrations are concerned. It may 
even reach the lower limit of the sound scale, as we can convince our 
selves for example in cases where the drum membrane is balasted by ex- 
tensive deposits of chalk in the intermediary zone. 

We can however easily imagine that hearing is seriously interfered 
with by every increased balasting of the sound-conducting chain, espe- 



Otitis Media Subacuta. 163 



daily for such noises as constitute the consonants of our whisper, which 
produce a whirl of rapidly dying away systems of sound waves. 

The disproportion between the hearing of speech and hearing of low 
sounds which are not perceived by air conduction in the other affections of 
the sound-conducting apparatus, can be thus understood in exudative 
processes of the drum cavity. 

The above-described inflammatory symptoms of otitis media simplex 
acuta may develop to various degrees of intensity. The injection of the 
blood vessels may in one case be confined to the vessels of the handle of 
the hammer, in another case the whole membrane may show radiar injec- 
tion, while in still another the surrounding meatus also may appear dif- 
fusely red. 

Pronounced injection, extravasations of blood, serous and hemor- 
rhagic blisters are found more frequently at times when there is an epi- 
demic of influenza and we are often surprised to see how quickly these 
violent forms of inflammation disappear again. 

Deafness is by no means always in proportion to the outwardly visi- 
ble symptoms of inflammation. It depends mainly upon the swelling and 
the amount of exudation in the middle-ear and may remain considerable 
for weeks or even increase after the injection of the drum membrane has 
disappeared. 

Each inflation of air through the tube, as long as there is considerable 
swelling or gathering of secretions in the drum cavity, produces only mod- 
erate improvement, which disappears again after a short time. We hear 
the air striking against the drum membrane at irregular intervals some- 
times for a single moment only and then with a clapping noise if we aus- 
cultate the ear by means of an auscultation tube while inflating air through 
the catheter. 

The duration of the disease sometimes extends over a few days only, 
and rarely transgresses several weeks, if a perforation does not occur, con- 
verting thereby the simple inflammation into a suppurative one. The 
symptoms of the inflammation of the middle ear gradually change back 
into those of occlusion of the tubes if the inflammation developed on the 
base of a pre-existing occlusion. 

We call otitis media simplex subacuta those cases which present no 
distinct symptoms of inflammation other than the characteristic functional 
disturbances. These forms of disease concern more frequently both ears 
and run a more prolonged course. Lues is sometimes found in connection 
with them. 

The prognosis of acute simple otitis is favorable throughout, also 
concerning full recovery of hearing, as long as a perforation of the drum 
membrane with its consequences for the surroundings of the ear does not 
occur. Some deafness however often remains in otitis media simplex sub- 
acuta. This may be partially due to the incompleteness of our diagnosis, 
as mistakes are easily made, on account of the negative findings of the 
drum membrane, if no careful functional tests are made. 



164 Treatment of Otitis Media Acuta and Snbacuta. 

For treatment of otitis media simplex acuta and subacuta consider- 
able importance was always accorded to the simultaneous treatment of the 
nose and naso-pharynx. There can be no doubt but that a great number 
of acute inflammations of the middle ear can be prevented by prophylac- 
tically removing different causes for occlusion of the tubes, like adenoid 
vegetations, crusts in ozena, etc. 

It seems sufficient however, to keep away harmful influences like 
smoke, dust, etc., if an acute otitis media has set in during a simple acute 
catarrh of the nose, or an angina, an influenza or an acute infectious 
disease. The washings of the nose which are so frequently used, even 
where no adherent and decomposed crusts have to be removed, are cer- 
tainly not as harmless to the ciliated epithelium as is often maintained. 
The dangers of constant reinfection from the nose through the tube are 
overestimated according to my experience. There are mainly the nasal 
douches which if awkwardly handled by the patient may cause the en- 
trance of infected fluid through the tube into the drum cavity. Gargles 
in the above stated manner (page 141) with normal salt solution or boric 
acid are indicated whenever there is considerable secretion in the naso- 
pharynx. 

Most authors caution against removal of the pharyngeal or faucial 
tonsils during the hight of an inflammation of the middle ear. 

The patient ought to be kept in bed as long as he has an elevation of 
temperature, the bowels must be well looked after and a moderate diapho- 
resis ought to be induced. Physical and mental exertion as well as al- 
cohol must be avoided. Quick improvement of the power of hearing is 
sometimes observed after a Roman-Irish bath, if the course is protracted, 
especially in subacute cases. Cold douches on the head must be avoided; 
it is better to cool the head by application of cold moist towels. 

The local pains may call for small doses of morphine (0.01) of 
phenacetin (0.75 pro die). The ice bag is applied over the mastoid process 
if the pain persists. Leeches and painting of the mastoid process with 
iodine had better be avoided, as they interfere with the observation of the 
mastoid process which may give us important points as to the spreading 
of the inflammation into the cells of the mastoid process, determining our 
further therapeutical actions. 

The inflation of air through the catheter or by means of Politzer's 
method is, from the very beginning of the inflammation, by far the most 
important and the most effective local remedy. 

Considerable aversion against inflation of air has been current during 
the last few years among a large number of otologists who think they 
ought to warn against its use during the hight of inflammation. The 
aversion is based on theoretical considerations and was prevalent once be- 
fore at the time of v. Troeltsch. I consider this anxiety absolutely un- 
justified after many years of experience, as do my disciples, and as 
to its unrestricted use, I take v. Troeltsch's standpoint whose words I 
repeat as they are valid to this day : 



Treatment of Otitis Media Acuta and Subaaita. 165 

"According to the statements of many authors I was formerly very 
timid as to the use of the catheter in acute diseases of the tympanic cavity 
and waited until all symptoms of inflammation had disappeared for fear 
of causing pain or harm to my patient. Now it is generally recognized 
that the earlier we use the catheter and the sooner we institute a local 
therapy calculated to spread and remove the secretions, the more we are 
able to shorten the inflammatory state. The passing of the air, which is 
no doubt difficult, instead of increasing the pain in the ear causes the pa- 
tient's head to feel lighter and the pain to diminish perceptibly, though not 
always immediately. In short all his sufferings take a turn for the better. 
. . . It is sometimes surprising how after inflation the soreness of the 
mastoid process which was extremely sensitive to pressure and even to 
touch, decreases." 

We will understand the favorable effect of the entrance of air into 
the middle ear when we consider that even in those cases in which the 
acute inflammation did not develop in connection with a pre-existing 
chronic occlusion of the tubes, the tube is occluded for some time during 
the hight of inflammation by swelling and gathering of tenacious secre- 
tions, and that all the consequences which we discussed in pure occlusion 
of the tubes will follow, such as rarefaction of air, hyperemia ex vacuo and 
transudation. The inflation of air has besides the instantaneous effect, a 
lasting influence on the course of the whole process of inflammation by re- 
storing normal air pressure and spreading the secretions over a larger ab- 
sorbing surface. We hardly ever have to recur to anodynes if inflation 
of air is practiced from the first day. 

Its daily use is indicated as long as hearing is considerably dimin- 
ished. Later on it depends on how long the improvement of hearing 
lasts each time. We repeat it as often as it becomes worse. 

The inflation through the catheter is preferable to Politzer's method 
for a number of reasons : 

Firstly, in using the catheter we are able to hear the noises and de- 
termine with our own ear whether or not the air penetrates as far as the 
drum membrane. 

Secondly, we confine the inflation with the catheter to the diseased 
ear. 

Thirdly, the current of air lasts much longer and its force can be 
regulated much better than in Politzer's method, where it enters only the 
moment of the act of swallowing and then often with a much greater 
force than we intended. 

We will therefore use the catheter in the adult wherever the anatom- 
ical conditions in the nose permit. Politzer's method is however abso- 
lutely indispensable in children; through it acute inflammations of the 
middle ear, also affections of the tubes first became accessible to treatment. 

Paracentesis of the drum membrane may become necessary in otitis 
media simplex acuta as we can not approximately estimate the amount 



166 Treatment of Otitis Media Acuta and Subacuta. 

of secretions gathered in the middle ear, nor whether they will be absorbed 
or will spontaneously perforate later on. The cases in which paracentesis 
is followed by a suppuration lasting for days or weeks are counted among 
otitis media purulenta acuta according to our principles of classification ; 
if no suppuration follows they are counted among otitis media simplex 
acuta. Paracentesis was performed in 4.4% of cases without consecutive 
suppuration worth mentioning among the 935 cases of simple acute 
otitis media of my statistical compilations. The precautions during and 
after paracentesis are the same which I recommended to you in gathering 
of serum in occlusion of the tubes. 



LECTURE XVIII. 

Acute Inflammation of the Middle Ear with 
Perforation of the Tympanic Membrane. 

Otitis Media Purulenta Acuta. 

Gentlemen : — We call acute suppurations of the middle ear all those 
cases in which a perforation develops in a previously intact drum mem- 
brane followed by a purulent discharge from the meatus. All cases in 
which we prevent the spontaneous perforation of the pus by a paracentesis 
come also under this heading upon the condition that the succeed- 
ing suppuration corroborates the accuracy of our diagnosis. An acute 
suppuration in the middle ear may finally perforate, not through the drum 
membrane, but through the bony walls at various places of these extensive 
cavities and extend into the surroundings, under the periosteum or the 
nearest soft parts. These may be the outside surface of the mastoid proc- 
ess, its lower surface along the bony meatus or finally on the cerebral 
surface of the temporal bone, raising the dura along the sinus sigmoideus, 
or the tegmen tympani et antri or at any other part of the dura as far as 
the diseased pneumatic cavities of the middle ear may extend. 

Our attention is often directed toward an extension of this kind by 
the long peristence of the functional disturbance accompanying an acute 
otitis media simplex and a number of other local and general symptoms 
indicating the opening of the cavities of the middle ear by operation. In 
cases which are not accompanied by a perforation of the drum membrane, 
the finding on opening of pneumatic cells filled with pus puts us in a posi- 
tion to verify the accuracy of our diagnosis of acute suppuration of the 
middle ear. 

We shall see how we differentiate otitis media purulenta acuta from 
otitis media purulenta chronica in describing their clinical picture and the 
course of recovery. 

It seems superfluous to me to put subacute suppurations of the mid- 
dle ear under a separate heading as some authors do, because subacute 
like acute suppurations usually heal with closing of the opening in the 
drum membrane, and no distinct line can be drawn between the two. 

167 



168 Otitis Media Purulenta Acuta or Perforativa. 

Otitis media purlenta phthisica has been classed with chronic suppu- 
rations of the middle ear, for reasons which we shall give later on. 

Otitis media purulenta acuta was observed in 6.4 per cent of ear pa- 
tients according to my statistics extending over 21 years. 

Children are represented by 4.1.4. per cent, which is nearly double the 
number of otitis media acuta and subacuta simplex (22.5 per cent) but 
not as many as in simple affections of the tubes (55.7 per cent). 

Acute suppuration of the middle ear attacked both ears in only 14.0 
per cent while otitis media simplex acuta and subacuta attacked both 
ears in 31.1 per cent and affections of the tubes in 77.0 per cent of cases. 

The latter figures are of special interest as to pathogenesis since they 
show that there must be local causes often confined to one side only, in 
the development of suppurations of the middle ear from occlusion of the 
tubes, and also from an increase of simple otitis media to well defined 
suppurations. 

It must not be forgotten that the statistical figures of the ear surgeon 
can not approximately give an accurate idea of the real frequency of 
acute inflammatory processes in the middle ear, neither as to otitis media 
simplex acuta and subacuta nor as to otitis media purulenta acuta. 

We obtain much better information as to their frequency from syste- 
matically pursued examinations of the middle ears of cadavers. 

I have already explained to you (compare page 157) that in more 
than 80 per cent of all infants of less than six months variable quantities of 
partially purulent secretions were found in the middle ear. 

Purulent inflammations of the middle ear from the slightest to the 
most serious degrees were found in all post-mortems after measles, scar- 
let fever and smallpox. Similar observations were made in diphtheria 
and the other acute infectious diseases, though not always with the same 
frequency and intensity (compare page 160). 

The pathogenic bacteria found in infants are mostly pneumococci, 
while in measles and scarlet fever almost always streptococci are found, 
which are considered especially virulent in the middle ear. 

It is therefore fair to suppose that there is hardly a human being in 
whose middle ear there was not pus once or several times during life. 

The great majority of these inflammatory processes in the ear do not 
cause a perforation through the drum membrane or through any other 
part, and even run entirely hidden from our clinical observation. They 
only produce subjective and objective symptoms which draw our attention 
to their existence, after they have reached a certain degree of intensity. 

We can draw the important and consoling conclusion from all these 
facts gained by observation on the cadaver and on the living, that the lin- 
ing of the middle ear can get rid of a certain amount of purulent secre- 
tions and pathogenic organisms without our interference. The organ of 
hearing and its surroundings are in danger when the exudations and 
bacteria surpass a certain amount ; then some therapeutical action be- 
comes necessary. 



Acute Suppurative Inflammation of the Middle Ear. 169 

Another fact becomes evident from the pathologic anatomical obser- 
vations just described. We find all degrees of acute processes of inflam- 
mation in the middle ear which have no sharp limits, but pass in gradual 
transition one into the other. Still as before mentioned a separate discus- 
sion of inflammation of the middle ear with perforations of the tympanic 
membrane appear necessary, because with the occurrence of the perfora- 
tion something new is added, modifying the course of the inflammations 
causing complications, making the prognosis worse and changing our 
therapy. 

The etiology of otitis media purulenta acuta is the same as of otitis 
simplex acuta. It may occur just as well as a consequence of local harm- 
ful influences like nasal douche, traumatic rupture of the drum membrane, 
or in connection with long lasting occlusion of the tubes, a catarrh of the 
nose, an angina, as by a complication of the acute general infectious dis- 
eases, especially influenza, measles, scarlet fever, smallpox, typhoid 
fever. An erysipelas migrating over the surface of the drum membrane 
may sometimes cause an acute suppuration of the middle ear. 

Special attention must be called to a few facts. Perforations fol- 
lowed by more or less profuse suppurations may arise from slight inflam- 
matory symptoms in the ear quite often in some general infectious di- 
seases, especially scarlet and typhoid fever, also after serious forms of 
measles and influenza, while the genuine cases of otitis after catarrh in an 
otherwise healthy organism rarely lead to perforation of the drum mem- 
brane. The difference between otitis arising under the influence of some 
general disease, and the genuine forms, becomes much more characteristic 
in their later course. Destructions, rapid enlargement of the perforation 
in the drum membrane, necrosis of the ossicles, necrosis of the lining of 
the middle ear and of its bony walls may progress under our eyes in the 
first class of cases, in a manner that we never see in an otherwise healthy 
organism. We have to admit from our observations, that the clinical pic- 
ture of acute otitis media becomes very much modified in the first place by 
any serious infectious disease diminishing the power of resistance of the 
whole organism. 

In attempting to study the clinical picture of pure otitis media puru- 
lenta acuta we have in the first place to exclude the different modifications 
caused by some serious general disease, and consider only the symptoms 
of the genuine acute suppuration of the middle ear, which occurs in an 
otherwise healthy organism either spontaneously or after catarrhs, etc. 
The acute influenza otitis does not materially differ from them as a 
whole. 

The inflammatory symptoms are more pronounced from the begin- 
ning on an average in the cases of otitis media purulenta acuta which lead 
to perforation of the drum membrane, than in otitis media simplex acuta 
which heal without perforation. This is not true for all, maybe not even 
for the majority of acute suppurations of the middle ear. A perforation 



170 Acute Perforative or Suppurative Inflammation of the M. E. 

occurs sometimes after moderate pain which lasts for a short while, per- 
haps for a few hours only, and without serious local reaction, especially 
in cases where the drum membrane is partially very thin on account of 
occlusion of the tubes existing for a long time, or from old suppurative 
processes healed by scars. 

The inflammatory reactions in case a perforation occurs in a for- 
merly normal drum membrane, are in the beginning similar to those de- 
scribed in otitis media simplex, only as a rule more violent. The tempera- 
ture especially in children may rise in the beginning of the disease up to 
104 F., and may exceptionally remain high for weeks. Cerebral symp- 
toms like vomiting, cramps, somnolence may usher in the disease. Tem- 
peratures of 104° F. before the perforation are however the exception in 
adults. The pains and pulsating noises are sometimes so disagreeable 
that colleagues for example often ask eagerly for a paracentesis, "even if 
the hearing be lost." The injection of the drum membrane is in such 
cases very marked and spreads diffusely over the deeper part of the bony 
meatus which may be concentrically narrowed on account of oedematous 
swelling Numerous hemorrhagic spots or serous and hemorrhagic blis- 
ters may develop on the tympanic membrane and extend far over the 
walls of the bony meatus especially during epidemics of influenza. An 
abundant fibrinous exudation sometimes forms on the excoriated sur- 
face after such a blister has burst. Its formation is always connected 
with exorbitant pain. 

A serious infiltration of the membrane, if its surface remained visi- 
ble, may be recognized by maceration of the external layers of the epi- 
dermis. They become white and crack in all directions, resembling an ir- 
rigated field of sand, which appearance they keep during the first few 
days after the perforation. 

The sensitiveness to pressure of the mastoid process is a symptom 
which allows us to draw the conclusion with reasonable accuracy that 
there are considerable quantities of secretion in the drum cavity and in 
the other spaces of the middle ear. There is especially one spot which 
must be considered characteristic in this regard. It is the rear end of 
the antrum found by pressure with the finger in the fossa mastoidea, di- 
rectly behind the line of insertion of the auricle. The point of the mastoid 
process also from the beginning is often sensitive to pressure. Pain ex- 
tends sometimes over the whole external surface of the mastoid process 
and its bony surroundings. 

Considerable relief is felt after the perforation of the tympanic mem- 
brane which sometimes occurs after a few hours, sometimes after a num- 
ber of days and after repeated increases and decreases in the violence of 
all subjective symptoms. Pain and increase of temperature may persist 
during the following few days. 

The discharge which occurs after the perforation took place is 
muco-purulent in the milder forms from the beginning, in the more 



Acute Purulent Inflammation of the Middle Ear. 171 

violent ones serous during the first few days, although containing numer- 
ous leucocytes. It is more or less hemorrhagic and so profuse that for 
days the cotton is soaked every 5 to 10 minutes. The quantity of the se- 
cretion corresponds probably to the extension of the diseased cells, but 
it may be extraordinarily abundant even in infants. The secretion be- 
comes muco-purulent after having been serous for a few days. Toward 
the end it becomes gradually semi-transparent, i. e., containing less cells, 
though it always remains more or less viscid. Discharge usually stops 
rather suddenly when the perforation of the membrane closes. 

The opening which forms in genuine acute suppuration of the mid- 
dle ear in an otherwise healthy organism and in a formerly normal drum 
membrane, in most cases can not be seen as such while examining with the 
speculum. It is always small and does not enlarge during the course of 
the disease. Its margins are so much swollen on account of the inflam- 
matory reaction pertaining to the healthy organism, that they touch each 
other the next day, even though we enlarge the opening by paracentesis. 

Its place, however, can easily be recognized from the constantly re- 
turning drop of fluid. In case it does not appear spontaneously the patient 
may either be asked to perform Valsava's experiment or while an assis- 
tant performs Politizer's method we inspect the drum membrane and see 
the fluid escaping from the opening at the time the air is forced into the 
middle ear. Very extended pulsating motions can often be observed on 
the light reflexes forming on the fluid in the external meatus. This mo- 
tion is transmitted to the fluid by the highly injected blood vessels of the 
middle ear. 

A noise of perforation is sometimes not heard at all, sometimes only 
if considerable air pressure is produced on account of swelling of the 
walls of the tube and of the tympanic cavity. Corresponding to the 
narrow opening more or less obstructed by tenacious mucous a shrill 
sound is produced and can be heard at a great distance. 

Many wrong ideas are prevalent as to the position of the perforation 
in the drum membrane. A number of text-books say that it is usually in 
the inferior anterior quadrant, and some authors believe that they saw 
an acute perforation in the membrana flaccida Shrapnelli. Mistakes as to 
the position are easily possible, because the limits between the membrane 
and the meatus, owing to swelling and redness, have more or less dis- 
appeared, and on the other hand, because a large part of the membrane 
is often covered from our view, by the bulging and later on granulating 
upper part of the membrane which comes very close to the anterior infe- 
rior wall of the meatus. 

The real seat of the perforation in such cases can only be located 
after long continued observation and careful sponging with a probe 
wrapped with cotton. 

Careful observation of many years especially directed to this point 
taught me that a perforation in genuine acute suppurations of the middle 



172 Acute Purulent Inflammation of the Middle Ear. 

ear is only exceptionally located in the anterior inferior quadrant and 
never in ShrapnelVs membrane. In the vast majority of cases I saw it 
in the rear half of the membrane and most frequently in the posterior up- 
per quadrant, less frequently in the posterior inferior quadrant or below 
the umbo. It is always in the thinnest intermediary zone of the mem- 
brane. 

All these details are important for the prognosis. A perforation 
which is clearly visible as a black hole points to deficient reaction of the 
margins. This may be due to the fact that it occurred in an old atrophic 
scar of the tympanic membrane or that the reaction is wanting on ac- 
count of some serious general disease. A more or less pronounced ten- 
dency to spreading of the destruction of the membrane is even charac- 
teristic for suppurations of the middle ear which develop as a complica- 
tion of some general disease. The position of the perforation in these 
cases also differs frequently. We find a hole in the anterior inferior 
quadrant especially in tuberculosis, where it appears to be small because 
we can only partially see the anterior inferior quadrant. In other cases 
of tuberculosis it is in the periphery and enlarges under our eyes, or mul- 
tiple perforations develop. All these occurrences simply do not happen 
in a healthy organism and in an otherwise normal membrane. The con- 
dition of the perforation is therefore to a certain extent a gauge for the 
seriousness of the constitutional changes during some general disease. 
A fresh perforation sometimes becomes larger in old people, and also in 
septicopyemia, whether of otitic origin or not. 

It is often impossible to decide whether the yellow spot of pus on the 
top of the prominence corresponding to the perforation is in the rear up- 
per quadrant or in ShrapnelVs membrane if the margin of the membrane 
is effaced by swelling and redness. Continued observation may later on 
convince us that the perforation is not above but below the rear liminal 
strands of the membrane. Even the pictures of so keen sighted an ob- 
server as Politzer could not convince me in this regard. Fibrinous exu- 
dations on the tympanic membrane and formation of protuberances in 
the rear upper quadrant, etc., may easily mislead us. 

We shall see later on in speaking about chronic suppurations of 
the middle ear with formation of cholesteatoma how perforations of 
ShrapnelVs membrane really occur. 

The opening in the tympanic membrane may temporarily close when, 
in the course of the inflammation, the secretion decreases. It sometimes 
gathers anew and bursts through the scar. 

Considerable swelling of the margins of the perforation sometimes 
causes the formation of a large conical prominence. A red button-like 
growth is seen on its top through which the pus discharges. Cone-shaped 
perforations are found especially when profuse discharge has existed for 
a long time ; or in the first few days of violent inflammations, especially 
in influenza-otitis. This growth, if removed with a snare, shows a long 
perforating central canal similar to a fistula. 



Acute Suppurations of the M. E. in Infectious Diseases. 173 

The power of hearing decreases even more in the course of an acute 
suppuration of the middle ear than in otitis media simplex. Whisper is 
however always understood at a distance of several centimeters by an ear 
which was normal before ; an a' tuning fork can also be perceived for 
some time by air conduction, if the labyrinth is not implicated in the in- 
flammation to any great extent. 

The examination of the lower limit, Schwabach's and Rhine's 
tests give similar results as in otitis media simplex acuta (compare 
page 162). A considerable loss of hearing of the highest sounds is often 
found down to the mark 3 of Gait oil's whistle (18,000 v. d.). 

The suppuration may have run its course in a few days, but it may 
also last several weeks or months with or without interruptions. I have 
seen it last even longer than a year in some cases, and yet it healed, the 
perforation closing and the normal function returning. 

I have never, in an otherwise healthy organism, seen a genuine sup- 
puration of the middle ear become chronic nor develop a persisting or 
enlarging perforation. 

The clinical picture of the numerous acute suppurations of the mid- 
dle ear occurring in connection with different acute general infectious dis- 
eases varies greatly in many regards. 

A large perforation may, though exceptionally, form in more violent 
forms of influenza otitis together with extensive extravasations of blood 
and blisters which were mentioned as characteristic. Large perforations 
are more frequent in otitis in connection with measles and typhoid fever. 
I saw 48 cases equal to 4 per cent, of acute suppurations of the middle ear 
in 1,243 cases of typhoid fever, most of which had large perforations in the 
membrane. In comparison to other diseases the ear suffers rarely in diph- 
theria but in some epidemics of scarlet fever Burkhardt-M erian found 
even 33.3 per cent of such complications. These cases do not only show 
the most extensive destructions but they even most frequently involve both 
ears. The ossicles may be expelled after a few weeks. More or less 
complete deafness may result from implication of the labyrinth. Among 
233 acquired deaf-mutes I established scarlatina as the cause of this afflic- 
tion in 42, equal to 18 per cent. 

The clinical picture in the ear differs totally from the very begin- 
ning from that in genuine suppuration of the middle ear. I saw for ex- 
ample discolored fetid secretions in the meatus of an ear in which an ex- 
tensive perforation had taken place during the previous night. Fetid 
secretions in acute genuine suppuration of the middle ear occur very 
late and only as a consequence of gross neglect. 

I saw another case where within six days the whole tympanic mem- 
brane was destroyed and the handle of the hammer became necrotic at 
the hight of scarlet fever. The prognosis as to the general disease in 
the face of such a rapid destruction is with great certainty fatal. 

Paralysis of the facial nerve, an extreme rarity in genuine forms, 
is often seen here. 



174 Treatment of Acute Suppurative Inflammation of the M. E. 

The glands are usually more swollen than in genuine otitis, and may 
suppurate, which never happens in genuine otitis. 

We shall see later on what a large number of chronic suppurations 
with all their consequences have to be attributed to scarlatina. 

We will now discuss the treatment of uncomplicated cases of otitis 
media purulenta acuta. 

Inflation of air into the middle ear is the remedy which at the 
very beginning of the inflammation, when it may still be doubtful whether 
we have to deal with a simple or suppurative form, often soothes the sub- 
jective symptoms to such an extent that we can avoid the use of ano- 
dynes. It ventilates the spaces of the middle ear and aids absorption 
of the secretions by spreading them over a larger surface. We apply 
an ice bag to the mastoid process at the same time and keep the patient 
in bed whenever possible. A paracentesis with the described precautions 
(compare page 152) is indicated if serious symptoms of inflammation, es- 
pecially sensitiveness to pressure of the mastoid process, persist until the 
next day or if the hearing distance decreases and the bulging of the mem- 
brane increases. 

Some colleagues try to avoid this small operation in many cases. I 
can not support this standpoint as I became convinced from many years 
of experience that early paracentesis affords speedy relief and shortens 
and ameliorates the course of the process. 

The paracentesis is succeeded by inflation of air in order to evacuate 
the secretions from the drum cavity. We perform the inflation through 
the meatus especially when otitis occurs in the course of some general 
infectious disease and in ozena, as we are able to disinfect the meatus, 
but never the complicated cavities of the nose and naso-pharynx. We do 
not need to be afraid of Politzer's method later on, after the nose and 
naso-pharynx have become free, it then forms an essential part of each 
cleaning of the middle ear. Irrigations of the tympanic cavity through a 
catheter in the tube which were formerly so frequently used, are now 
generally recognized as harmful and have therefore been abandoned. 

To give you an idea of how frequently paracentesis is indicated I 
might say that it was performed 454 times, equal to 27.1 per cent, in 1,677 
cases of otitis media purulenta acuta observed from 1887 to 1901. 1 ) 

In 1879 shortly after Lister established the antiseptic properties of 
boric acid which came into his hands as a secret remedy from Sweden, I 
reported its favorable influence in powder form, in acute and chronic sup- 
purations of the middle ear. 2 This was at a time when the bacterial 
origin of these processes was unknown, as is evident from the expression 
"acute and chronic purulent catarrh" which was then used. Antiseptic 



1 DOlger, Die Mittelohreiterung, auf Grundlagen der statist. Berichte Bezolds 1869—1896. 
Mtinch. 1903. Lehmanns publ. (Table IV). 

2 "Zur antiseptischen BehandlungderMittelohreiterungen". Arch. f. Ohrenhlk. vol. XV. 1880. 



Treatment of Acute Suppurative Inflammation of the M. E. 175 



remedies were then only used in fetid otorrhoea, namely, solutions of 
permanganate of potash and carbolic acid which are very injurious to the 
lining of the middle ear. 

The treatment of acute and chronic suppurations of the middle ear by 
means of boric acid prevailed during the next few years until Schwartze 
cautioned against the use of the powder on account of retention of secre- 
tions in small perforations situated high up in the membrane. This com- 
plaint was repeated over and over again by some colleagues, although a 
number of older authors who became well acquainted with treatment by 
means of boric acid, called the scruples of Schwartze exaggerated. 

All the manifold dangers of acute suppurations of the middle ear 
became apparent only since then, when also their real connection with the 
local focus of the disease was carefully studied. 

Very careful histories were kept in my statistical records, extending 
over 28 years, of all fatal and non-fatal complications of suppurations of 
the middle ear. My conviction that there is not 
one case in which boric acid treatment can be 
kept responsible for the dangerous occurrence is 
based on this large material. 

We are able by means of boric acid treatment 
to avoid reinfections from the meatus through the 
opening in the drum membrane in acute suppura- 
tions of the middle ear, even though its influence 
is not quite so evident there as in chronic cases 
containing putrid decomposed secretions. 

Secondary otitis externa, excoriations, forma- 
tion of granulations and furuncles in the walls of 
the meatus, formerly so frequently seen as conse- 
quences of large quantities of pus constantly pass- 
ing through the meatus, have nearly entirely 
disappeared since boric acid treatment was intro- 
duced. 

The insertion of a strip of gauze down to the 
tympanic membrane and tamponade of the meatus 
so much used during the last few years can only safely be performed by 
the hand of a physician, and is a poor substitute for boric acid powder, 
since it rests on the membrane and absorbs the secretion by capillary 
attraction. 

There were only very few cases of idiosyncrasy against boric acid 
powder in patients otherwise disposed to eczema. This idiosyncrasy 
showed itself in eczema spreading over large areas of the face, starting 
from the meatus (compare page 85). We confine our treatment in such 
cases to washing with 4 per cent solutions. 

Our procedure after performing a paracentesis is as follows : 




Simpl 



Fig. 61. 
e powder blower. 



176 Treatment of Acute Suppurative Inflammation of the M. E. 



Inflation of air through the meatus and insufflation of carefully dried 
boric acid powder by means of a powder blower, consisting of a rubber 
bulb and tube into which a glass tube is inserted, which can be changed 
for each patient. 

The ice-bag is used for hours at a time as long as the mastoid process 
is at all sensitive to pressure. Patients who could not stand the ice-bag 
were hardly ever met with, therefore there was never any need of replac- 
ing it by warm linseed poultices. 

Leeches have not been used for years, as in producing lymphangitis 
they often interfere with our decision, concealing those very important 
symptoms (sensitiveness to pressure) on the mastoid process. 

An injection of 4 per cent warm boric acid solution is made not of- 
tener than once a day, no matter how profuse the suppuration may be. 

Inflation of air by means of Politzer 's method follows this procedure 
if the naso-pharynx is free from inflammatory secretions, otherwise the 
inflation takes place through the meatus. 

The fluid, in syringing passes only excep- 
tionally through the narrow opening in genuine 
acute suppurations of the middle ear even though 
high pressure is used. This however occurs reg- 
ularly in the larger perforations, formed in the 
course of otitis following acute infectious dis- 
eases. Therefore we have to be more careful in 
those cases. Children ought to be laid face down- 
ward during the injection, so that the fluid may 
run through the nose, and that they may not swal- 
low too much of the saturated solution of boric 
acid. 

The careful drying of the meatus is a very 
important point. It is accomplished by spong- 
ing with a probe without a probe-end wrapped 
with cotton, and curved to correspond to the axis 
of the meatus (compare fig. 62) ; in order to 
reach the deepest parts of the recessus. 

The patient is requested to repeat Valsalva's 
experiment at short intervals when each drop 
showing at the perforation, is caught with the 
probe wrapped with cotton. This is repeated 
under control through the speculum till no drop 
shows and all secretions are removed from the tympanic cavity. The 
powder is then insufflated. 

Here are the most important advantages of this method: Firstly, 
the secretions never become fetid. This only occurs very exceptionally, 
in acute suppurations, usually after some unsuitable treatment, like poul- 
ticing. 




Fig. 62. 

Probes for the right 
and left meatus. 



Treatment of Acute Suppurative Inflammations of the M. E. 177 

Secondly, the meatus remains free from inflammations and swelling 
during the whole duration of the treatment. 

The epidermis of the external canal in patients who consult us after 
the perforation has existed for some time, is generally considerably thick- 
ened and macerated. It becomes smooth, the excoriations heal in a few 
days and the canal remains without symptoms of inflammation during the 
entire treatment. We are able to see the whole tympanic membrane at all 
times, and especially to recognize the very beginning of the ominous 
swelling of the rear upper bony wall of the meatus indicating a more in- 
tensive implication of the cells of the mastoid process. 

Small operations on the tympanic membrane very often become neces- 
sary in the course of the suppuration. 

A perforation located, as it frequently is, in the rear upper quadrant 
must be enlarged downward by means of a lance-shaped (not sickle- 
shaped) knife. 

The paracentesis must often be repeated four times and more at the 
same place, as soon as it becomes impermeable to air during inflation and 




Fig. 63. 
Wilde's snare. 

when pus gathers again, sometimes showing through the bulging mem- 
brane. 

Special attention must be paid to the button and nipple-shaped 
growths on the place of the perforation. They must be split downward if 
they are in the rear upper quadrant or a new incision in the rear lower 
quadrant must be made as soon as the growth interferes with the free 
passage of secretions or air during inflation. 

They are removed by means of Wilde's snare (compare fig. 63), if the 
growths are large enough. The growth has a central aperture if we suc- 
ceeded in removing it at its base. We have therefore shortened the length 
of the canal of perforation to the extent of the hight of the growth 
thereby creating better drainage. These growths especially in influenza 
otitis have a peculiar tendency to quickly reappear, requiring repeated 
removal by means of the snare. 

I never destroyed the growths by means of chemicals or galvanocau- 
tery, since I do not consider indifferent the formation of a scab or inflam- 
matory reaction at the place of perforation. 

12 



178 Treatment of Acute Suppurative Inflammation of the M. E. 

The removal of the growth by means of the cold snare and the para- 
centesis performed under antiseptic conditions are never followed by in- 
flammatory reaction, and are entirely sufficient to keep the opening patu- 
lous until the suppuration in the tympanic cavity ceases. 

The safest criterion for allowing the opening to close is the return 
of a more or less normal hearing distance of 4 to 5 meters for whisper. 

After the perforation has closed it is advisable to continue the infla- 
tion of air at greater intervals, in adults by means of the catheter, in chil- 
dren by means of Politzer's method, until the patient hears no more noises 
while blowing the nose and hearing has become entirely normal. 

Although hearing of speech has become normal the tuning fork on 
the vertex may still be heard in the affected ear for a comparatively long 
time and the highest sounds, that normally can be heard and are produced 
by Galton's whistle, can not be perceived. 



LECTURE XIX. 

Empyema of the Mastoid Process in Acute 
Inflammation of the Middle Ear. 

Gentlemen: — The various diseases which may develop as conse- 
quences of acute inflammations of the middle ear are induced almost with- 
out exception by an intense and extended implication of the pneumatic 
cells which converge into the mastoid antrum. 

The antrum and the cells probably always take part in even the 
slightest inflammations of the middle ear which show any clinical symp- 
toms. Every one can easily convince himself of this fact by examining 
at the post-mortem table a number of organs of hearing of people who had 
acute exanthemata, but never showed any symptoms during life. Topeitz 
and I for example found inflammatory processes in measles and v. Gass- 
ier in scarlet fever regularly, even during the first few days of the gen- 
eral disease. The process consisted of formation of muco-purulent or 
clearly purulent secretions, which were not confined to the tympanic 
cavity but extended over the antrum and the nearest pneumatic cells, 
although the outside of the tympanic membrane showed no inflammatory 
symptoms whatsoever. Streptococci and other pathogenic organisms were 
always present. 

The fact that an implication of the cells of the mastoid process is the 
rule even in the mildest forms of inflammation of the middle ear which 
remain absolutely latent, leaves no possible doubt that the same is true in 
all serious cases with perforation of the membrane. It is supported by 
our experience at the operating and post-mortem table. 

A spontaneous evacuation of purulent secretions which may have 
gathered in the complicated system of cells with narrow exits through a 
perforation or through the tube, is impossible. 

All the milder acute suppurations of the middle ear and the majority 
of serious ones nevertheless recover without operation if decompositions, 
etc., acting from the outside and in the meatus can be kept away. The 
supposition is therefore justified that the purulent secretion in all cases 
which recover spontaneously is absorbed in the cells. 

179 



180 Acute Empyema of the Mastoid. 

The secretion perforates however in some cases through the bony 
walls of the cells into the soft tissues surrounding the temporal bone on the 
outside and the inside. The consequence of such a perforation is a gath- 
ering of pus either between the periosteum and the bone or in the inter- 
stitia of the soft tissues which is identical to an abscess. 

The cause for the fact that a perforation occurs and that no absorp- 
tion of pus in the cells takes place must not be sought for in the nature, 
nor in the quantity, nor in the virulency of the pyogenic organisms, but in 
special anatomical conditions ; superficial position of the cells, thinness 
and dehiscencies of their walls, and especially single cells of very large 
size. 

The superficial position of cells filled with pus often becomes evident 
in operation, when the first blow with the chisel evacuates pus. The im- 
portance of the size of each single cell for the absorption of the pus 
becomes evident, if you remember that the surface of a ball increases in 
proportion to the square of its diameter, while its contents, to the cube. 
The power of absorption of the walls decreases therefore with the increase 
of the size of the cell. The smaller the single cells are, the easier they 
will master the pus they contain and the number of cells that are inflamed 
is immaterial. 

You will remember that I told you in describing the anatomy that the 
terminal cells are in the periphery, far away from their central confluence, 
the antrum, and that in some cases they form very large round cavities. 
An empyema, i.e., a gathering of pus which can not be spontaneously ab- 
sorbed may develop wherever there are such large terminal cells in a 
temporal bone. 

Schcibe very accurately described the histological processes occurring 
in such large cells filled with pus. 1 

The lining of the cells contains very many blood vessels, is 40 to 80 
times as thick as in the normal and changed into a lobulated granulation 
tissue rich in lymphocytes. The bony inner surface of the cells is eroded 
all over by small dimples and in each one there is a multinuclear giant 
cell (osteoclasts). These erosions extend over the adjoining bony canals 
and cavities containing marrow, they become enlarged and contain more 
cells than normal. Little by little in all directions an excentrical enlarge- 
ment of the cavities filled with pus is thus effected, until it reaches the 
dura inwardly, or most frequently the protruding wall of the sinus and 
outwardly the periosteum at some place of the mastoid process. Thus a 
fistulous perforation occurs on the latter surface, if the process is not in- 
terfered with. The formation of osteoclasts and their bone wrecking 
occupation comes to a standstill as soon as the pus is evacuated, and a 
layer of cells containing one large nucleus takes their place on the walls 
of the diseased spaces. They are the osteoblasts which at once form os- 



i) Aetiol. und Pathol, des Empyems im Verlaufe der akut. Mittelohreiterg. Zeitschr. f. O. 
Vol. 48, 1904. 



Acute Empyema of the Mastoid During Infectious Diseases. 181 

teoide substance and this later on becomes ossified all around and in the 
focus. At a greater distance from the focus of suppuration the occupa- 
tion of the osteoblasts and the formation of osteoide tissue begins long 
before the evacuation of the pus. 

The picture of rarefying ostitis (Volkmann) and its process of heal- 
ing are so presented here that we can study them in rare perfection. 

Much confusion was produced in the ideas of otologists by calling 
this process caries, and we had therefore better avoid this expression here, 
as the term caries is applied to a progressive process of destruction of the 
bone. Destruction in the formation of an empyema progresses only until 
the pus at some place is drained from the bony cavity. New formation of 
bone takes the place of destruction as soon as drainage is accomplished. 
It fills the defects in a short time and progresses further, with the result 
that the cell becomes smaller than it was before the empyema. 

An admirable purpose becomes apparent from the whole sequence of 
these processes. 

The natural opening of these cavities does not occur as the surgeon 
dictates it, that is exclusively toward the outside, the enlargement of the 
cavity takes place excentrically in all directions. Sometimes the bony 
walls of the dura and sinus are destroyed to a large extent at the same 
time that the outside of the mastoid process is reached. The dura itself 
and the walls of the sinus however show a great power of resistance, at 
least in the healthy organism, although not without exception. They 
may be bathed in pus for weeks without sustaining any damage. The 
openings in the outer wall of the mastoid process are usually small and 
are found most frequently at the very place which for anatomical reasons 
appears the most suitable for artificial opening, namely in the fossa mas- 
toidea situated exactly outward from the antrum. The process of healing 
together with extensive restoration of bone lost either spontaneously or by 
operation requires, as we now know, from three to five weeks, if we at- 
tend to the drainage of the pus from the surrounding soft tissues and 
from the bone by sufficiently enlarging the perforation. 

Suppurations of the middle ear occurring as complications of some 
general disease do not run their course with the same typical regularity as 
those developing in the healthy organism. 

There is in the latter class of cases absorption of bone and very in- 
tense reactive inflammation of the soft parts. In the first class the soft 
tissues also may decompose, so that the bone becomes stripped and its nu- 
trition more or less seriously interfered with, pieces of bone of any size 
may later on be cast off as sequestra. For example in some cases 
which had to be operated upon during the hight of scarlet fever, measles 
or typhoid fever all the cells were found white and stripped of all soft 
parts after removal of the outer plate of bone at the surface of the mastoid 
process. All parts that are stripped of periosteum are only exceptionally 
expelled as sequestrum. As a rule the bone becomes pinkish and granula- 
tions begin to form on its surface though sometimes only after two weeks. 



182 Perforation of Acute Empyema Through the Surface. 

The formation of one or several small sequestra on the walls of the 
cells is not rare in connection with acute inflammatory disease. 

The diminished power of resistance and reaction is furthermore 
shown in those cases by a frequent participation of the facial nerve and 
the extension of the suppuration to the labyrinth. 

We can not always expect a typical course of the process of recovery 
in the cases connected with some general disease, even if we interfere 
in time. In the large majority of cases however the process will take a 
more normal course as the general organism gradually recovers. 

We shall discuss here only the perforations of acute empyema at the 
outer surface of the skull and their symtomatology. 

The inward perforations and the intracranial complications in con- 
nection with them, have so many things in common with the sequelae of 
chronic suppurations of the middle ear, that we had better discuss them 
later on. 

The outer surface of the mastoid process, as was before mentioned, 
is the most frequent location for the formation of a fistula. Perforations 
at the lower surface of the temporal bones are less frequent, but not at all 
rare. The cells at the root of the zygomatic process finally may cause a 
perforation in only' very rare cases. 

The three different locations possible of the perforation produce three 
characteristic clinical pictures. 

I. Perforation through the outer surface. The sternocleido mastoid 
muscle, the splenius and longissimus capitis muscles are inserted at the 
posterior inferior part of the outer surface of the mastoid process. The 
most frequent case is a perforation above the insertion. The escaping pus 
can detatch the periosteum downward only as far as this line of insertion, 
and the point of the process as well as its surroundings remain free from 
swelling. The elevation of the periosteum extends below the auricle 
which does not insert in a simple curved line but into a broad surface of 
the bone (compare fig. 16 page 33). The consequence is a change of 
position of the auricle on the side of the head, namely, an elevation, a more 
or less perpendicular position and a drooping of the upper part sometimes 
amounting to 2 centimeters. The swelling very soon begins to fluctuate 
in the depth, and the subperiostal abscess extends backward, upward and 
forward at varying distances according to its duration. The swelling, but 
never the fluctuation, may extend below the insertion of the muscles down 
the neck, if there is not a second perforation below those insertions. 

This form is most marked and most characteristically developed in 
children whose temporal bones have developed no pneumatic cells down- 
ward and inward. Although they have no cells, the empyema in children 
of a few years perforates on the outer surface of the process much oftener 
producing subperiosteal abscesses than in adults, because their antrum is 
comparatively very large and its rear end is very superficial. The sutura 
mastoideo-squamosa runs vertically through the rear end of the antrum, 



Perforation of Acute Empyema. 



183 



it often persists in this age and favors thereby a perforation at this place. 
A large sequestrum, shaped somewhat like a pyramid, is formed which has 
for its limits forward the sutura tympanica posterior, backward the fis- 
sura mastoideo-squamosa and upward the crista temporalis (compare fig. 
64), if the process lasts for some time in a poorly nourished child, or after 
a serious general disease. The auricle as a whole moves far away from 
the skull, which position alone may suggest the presence of a sequestrum 
in the depth. The lymph glands surrounding the mastoid process may 
become considerably enlarged, and even, especially after scarlet fever, 
form an abscess, if there are general diseases or serious anomalies of con- 
stitution present. 

2. Perforation on the lower surface of the temporal bone. Excep- 
tionally large cells are often found in the adult and especially in later 
years, on the inner surface of the mastoid process, sometimes extending 
medial from the incisura mastoidea as far as the bulb of the jugular vein 





Fig. 64. 
Sequestrum representing the mastoid process of a child, removed by operation. 

a outer, b inner surface. 

(compare fig. jh). Their walls are often very thin and even have dehi- 
scences. Perforations in the subsequent course of acute suppurations of 
the middle ear at these places are therefore frequent in later years. They 
produce a very distinct clinical picture, differing completely from the fore- 
going, and in literature are often called Bezold's mastoiditis, because I 
studied its development experimentally on the cadaver. 1 

The pus escaping through these perforations cannot reach the surface, 
as they are below the very extended and solid insertions of those three 
muscles, and therefore below the deep fascia of the neck. No fluctuation 
can be felt. A moderately sensitive swelling develops rather suddenly in 
the lower surroundings of the mastoid process concealing its contours 
from the eyes and the palpating finger, after an otitis media purulenta 
acuta has lasted for weeks or months, or not rarely, even after it had 
ceased in the tympanic cavity, and a nearly normal hearing had returned. 
The suppuration spreads gradually in all directions in the interstitia of the 



1 "Ein neuer Weg far Ausbreitung eitriger Entzundung aus den Raumen des Mittelohres etc.' 
Deutsch. med. Wochenschr. 1881, No. 28. 



184 Perforation of Acute Empyema. 

muscles below the deep fascia of the neck. The pus may descend along the 
sheaths of the large vessels and may reach the larynx and even the medi- 
astinum if the process is not interfered with. The pus may descend by 
gravitation along the muscles of the vertebral column and we may be 
able, after opening the cells of the process, to evacuate pus from the cells 
by pressure on the neighborhood of the upper thoracic vertebrae. 

A burrowing of pus leading to the formation of a retropharyngeal 
abscess was observed on the anterior surface of the vertebral column. 
The pus in rare cases effected an exit by boring a fistula through the floor 
of the meatus. 

The cases which lead to these processes are not at all the most serious 
cases of otitis media purulenta acuta. A perforation of the tympanic mem- 
brane for example did not precede the descensions of pus in the neck in 29 
per cent of the cases I observed. 1 Pneumococci were found most fre- 
quently to be the cause of the suppuration. The process of suppuration, 
which may pass in the main spaces of the middle ear with slight symptoms 
and heal in a short time, may acquire an entirely different character in the 
far distant large terminal cells. This form of suppuration becomes more 
often dangerous to life than the other forms of empyema of the mastoid 
process, on account of the great extension in the neck of the abscesses by 
gravitation and on account of the frequently very extensive connection 
with the walls of the sinus. 

Abscesses by gravitation as were just described were found 17 times 
in 97 operations for empyema that were performed during the last 10 
years. You see they are not at all rare occurrences. 

It is very important for differential diagnosis of perforation of pus 
at the lower surface of the mastoid process, to remember that pneumatic 
cells leading to such perforations are not developed during the first years 
of life. A similar hard diffuse swelling at the lower periphery of the mas- 
toid process may occur in this early age in the course of an acute suppu- 
ration of the middle ear, especially in connection with some acute infectious 
disease, mainly scarlet fever. Some very much swollen glands may how- 
ever be felt more or less distinctly by palpation, while superficial fluctua- 
tion, which never occurs in perforation of pus through the floor of the 
mastoid process, must be attributed to the breaking down of some of the 
glands. A collateral oedema and redness of the whole auricle, which was 
never observed in deep perforation, occurs in these cases of lymphadenitis 
which apparently start from an inter current otitis externa. 

3. Perforation at the root of the zygomatic process. The third form 
is observed rarely and leads to elevation of the periosteum under the tem- 
poral muscle and to pronounced raising from the head of especially the 
upper half of the auricle. Sometimes the pus may descend below the arcus 
zygomaticus. 

Two of the described forms may occur together. 

An extradural abscess secondary to disease of the ear may finally find 

1 Leimer statistische Zusammenstellungen etc. Zeitschr. fur Ohren. Vol. 43 page 273. 



Schwartzc's Operation. 185 



an avenue outward along an emissary vein, thereby leading to a subperi- 
osteal abscess on some part of the outer surface of the skull. 

Mastoid Operation in Acute Inflammation of the Middle Ear. 

The manifold dangers which are involved in an acute suppuration of 
the middle ear justify a prophylactic interference instead of waiting for 
the perforation of the empyema or for dangerous general symptoms. 

The operation is indicated when a profuse acute suppuration of the 
middle ear lasts more than 8 weeks in spite of correct treatment. In the 
large majority of cases it discloses distant foci of suppuration of such 
dimensions that they would hardly ever have healed spontaneously. In- 
fants suffering from acute genuine suppuration of the middle ear must be 
excepted from this rule. A suppuration lasting for 8 weeks is not so im- 
portant in infants as it is in adults, because the cells of the mastoid are not 
yet developed and the sigmoid sinus has not yet dug a groove in the tem- 
poral bone deep enough to come close to the antrum. A perforation of pus 
at this age, occurs much more readily toward the outside than inwardly 
towards the cavity of the skull, thereby informing us in time of the neces- 
sity of operative interference. 

There are some local symptoms which may indicate an extensive im- 
plication of the mastoid cells much earlier, thereby justifying an operation ; 
for example lasting sensitiveness to pressure of some parts of the mastoid 
process, spontaneous pains irradiating towards the skull and interfering 
with sleep, pronounced swelling of the posterior superior bony wall of the 
meatus, and, combined with profuse suppuration, button-shaped growths 
on the tympanic membrane which reappear after removal. 

Other indications for opening the cells are, swelling on the outside of 
the mastoid portion which soon begins to fluctuate, or the characteristic 
hard swelling below the mastoid process, even though no perforation of 
the tympanic membrane has occurred, also if fistulas have formed any- 
where else in the vicinity. 

An operation is scarcely ever indicated before the end of the first 8 
to 14 days. 

Symptoms pointing to a threatened invasion of the labyrinth are of 
utmost importance. They are sudden pronounced disturbances of equi- 
librium combined with nausea, furthermore sudden and considerable de- 
crease of the power of hearing to such an extent that whisper is heard 
indistinctly close to the ear, the highest sounds are not heard as far down 
as the mark 4 or 5 of the Galton whistle. An a 1 tuning fork is heard 
only for a short time by air conduction. To relieve the pressure in the 
middle-ear by freely opening the cells is our urgent duty, if one or several 
of these symptoms are present, in order to prevent an invasion of the cav- 
ities of the labyrinth. A fatal meningitis can not be stopped in the major- 
ity of cases if a perforation and a consequent panotitis occurs, as is often 
seen in weak individuals and in old people. 



186 Technic of Schwartze's Operation. 

Another indication for mastoid operation in acute otitis is the appear- 
ance of facial paralysis. This is very rare. 

Intracranial complications and their symptoms calling for operative 
interference will be discussed later. 

Technic for Opening the Antrum — Schwartze's Operation. 

The necessity for the performance of a mastoid operation appears so 
frequently and sometimes so suddenly that every general practitioner 
ought to be acquainted with its technic. Injuries can easily be avoided if 
we are acquainted with the anatomy of this region and its frequent varia- 
tions. 

The operation ought to be previously practiced on the cadaver. 

The cut is made as a vertical tangent to the posterior insertion of the 
auricle from the crista temporalis to the point of the mastoid process, 
through the skin and periosteum. 

Wilde's incision which was used years ago was confined to incision 
through the soft tissues. It is insufficient because the suppuration always 
begins in large cells in the bone which therefore have to be drained. 

The periosteum is pushed forward and backward by means of a dull 
periosteum elevator. Thus the whole outer surface of the mastoid process 
is laid bare, from the crista temporalis and forward to the rear limit of the 
entrance to the meatus. The spina supra meatum appears directly behind 
and above the meatus and can always be found there, at least in the adult. 

This ridge has generally been accepted as the safest mark for finding 
the antrum, since I proved that its position as compared to the antrum is 
always the same. 

It is advisable to chisel away the whole outer plate of the mastoid 
process from its point to the crista temporalis and to the spina supra mea- 
tum, since usually a number of cells, especially far distant ones, take part 
in the suppuration. We obtain the smoothest field of operation by using a 
gouge about 15 millimeters wide with a convex cutting edge. We find the 
rear end of the antrum by penetrating to a depth of 10 to 12 millimeters 
in the angle between the crista temporalis and the spina supra meatum. 
We use the gouge flatly and from the rear for removing the outer plate ; 
in the fossa mastoidea horizontally in order to avoid the sigmoid sinus 
which is sometimes so superficial and so far forward that it may be un- 
covered with the first stroke of the hammer. For the same reason we re- 
move the cover of the point by chiseling from the point upward. It is 
sometimes necessary to remove the lateral part of the rear wall of the bony 
meatus when the sinus comes very far forward. 

Large cells filled with pus are most frequently found in the point of 
the process and on the rear margin of the pars mastoidea in the prolonga- 
tion of the incisura mastoidea upward and backward. 

The absorption of the bony walls of the cells, especially if the cells 
were large before they became diseased, may progress so fast that a few 



Schwartze's Operation in Acute Inflammation of the M. E. 187 

weeks after the beginning of an acute purulent otitis media the bony cover- 
ing of the sinus has disappeared and the wall of the sinus forms to a large 
extent the wall of the empyema cavity. Utmost care must therefore be 
taken when the granulations are scraped away by means of a sharp spoon. 

In cases of perforation through the floor of the temporal bone into the 
neck we often find the cell containing the empyema, medial of the whole 
mastoid process. In such cases it becomes necessary to chisel away the 
entire point of the process, regardless of the insertion of the muscles at- 
tached to it, whereupon we often find an unexpectedly large cavity filled 
with pus, extending along the sinus toward the bulb of the jugular vein 
which it sometimes reaches. Special care must be taken here also in 
removing granulations from such deep cavities in order to avoid injuries 
to the sinus and bulb. 

The whole territory is converted into one cavity by removing all the 
bony septa which divide it. 

Contra incisions, according to the rules of surgery, must be made on 
the neck if there are abscesses by gravitation. In these cases the pus 
comes close enough to the surface to be reached only after long duration 
of the process and sometimes in very distant locations. The removal 
of the mastoid process and of the lower wall of the cells medial of it, 
is sufficient in the large majority of cases in order to drain the pus gath- 
ered in the interstitia of the muscles. 

I saw perforations through the floor of the temporal bone only in 
adults. 

Diabetes is no contraindication against the opening of the mastoid 
process as was formerly thought. Experience has shown that recovery 
in diabetics does not take a materially different course than in the normal 
organism. 

We must remember that in children in the first years of life only the 
antrum has to be opened, which lies very superficial at its rear end. Nev- 
ertheless these operations occasionally offer considerable difficulties on 
account of the swelling of the soft tissues, sometimes amounting to 2 cen- 
timeters and more, combined with the smallness of the field for operation ; 
and also because both, the crista temporalis and the spina supra meatum 
may be absent in that period of life. A number of injuries to the dura 
followed by fatal meningitis are reported in literature caused by the 
difficulty of the anatomy together with the thinness and softening of the 
bone owing to rickets. 

It is fortunate however that in infants a fistula leading into the antrum 
often shows us the way, and we only have to enlarge it by means of a 
chisel 5 to 6 millimeters in width. There are either no cells at all or only 
in the direct neighborhood of the antrum. 

The wound is dusted with iodoform powder and lightly packed with 
iodoform gauze. The external meatus is carefully dried and some boric 
acid powder insufflated. The wound and the ear are covered with a 



188 Schwartze's Operation in Acute Inflammation of the M. E. 

large tuft of cotton over which a gauze bandage is run in circles around 
the head leaving the other ear uncovered. We avoid if possible to run the 
bandage under the chin as it feels uncomfortable to the patient. A 
starched bandage helps to keep the dressing in place, which may remain 
for six days provided the secretions were not fetid and no pains or fever 
ensue. Later on the dressings have to be changed every 2 or 3 days, often 
every day. 

The secretion from the meatus stops during the next few days and 
the perforation of the tympanic membrane closes, if no further complica- 
tions arise. The wound fills with granulations and newly formed bone on 
an average after 3 to 5 weeks and heals without leaving any deformity. 

The reports of ear clinics give an entirely wrong idea as to how fre- 
quently the opening of the antrum and mastoid cells becomes necessary 
in acute purulent otitis media, as the cases needing operation gather there 
from great distances. Counting only the cases of otitis media purulenta 
acuta which remained in our care from their beginning, their number 
amounts to little more than 1 per cent. 



LECTURE XX. 

Chronic Suppurative Inflammation of the Middle Ear. 
Otitis Media Purulenta Chronica. 

Gentlemen : — All inflammations of the middle ear which have a last- 
ing perforation or one that closes only' after years, and which shozv a con- 
tinual or temporarily recurring suppuration, are called otitis media puru- 
lenta chronica. 

Of all the patients whom I observed during the last 21 years 16.9 
per cent suffered from chronic suppuration of the middle ear. "Residues 
with persistent or closed perforation" are not included as they form a class 
for themselves. 

29.5 per cent were children. 

In 22.5 per cent both ears were affected. 

The large majority of patients suffering from suppuration of the 
middle ear ask the aid of an otologist only after years and scores of years 
of illness. 

This is one of the reasons why the study of pathogenesis is so very 
difficult. It is true that in the course of some acute infectious diseases as 
well as in consumptives we may witness the formation of large perfora- 
tions in the tympanic membrane, or the perforation enlarges to such an 
extent that it can not close spontaneously. It is however the minority of 
cases of chronic suppuration of the middle ear which can be traced back 
to some acute infectious disease or phthisis. 

Scarlet fever can by far the most frequently be accurately ascertained 
as the cause, namely in 13.8% of all the cases according to my statistics; 
measles only 1.6% and the remainder of the acute infectious diseases in 
still smaller figures. 

All genuine acute suppurations of the middle ear which came under 
our observation, and nearly all of the numerous cases of influenza otitis 
recovered in a comparatively short time, the perforation closing. Recur- 
rences are rare except in the cases which are due to acute recurrences of 
affection of the tubes. 

The origin of the large majority of chronic suppurations of the middle 
ear with persistent perforation remain therefore unexplained. 

189 



190 Chronic Suppurations. Central Perforations. 

We shall see later on that a large number of decidedly characteristi- 
cal forms with perforations of Shrapnell's membrane and the cholesteato- 
mata, must be attributed to long lasting occlusion of the tubes and are 
a consequence of partial relaxation and atrophy of the tympanic mem- 
brane. 

The perforations of the tympanic membrane in otitis media purulenta 
chronica are of the greatest variety as to form, size and position. 

Two kinds of perforations must be distinguished in regard to their 
origin and to the character and prognosis of the changes in the middle 
ear. Firstly the central perforations showing a remnant of the drum 
membrane at least along the whole upper part of the periphery which may 
be ever so narrow; secondly the marginal perforations, embracing all 
cases with total destruction of the membrane ; furthermore, all small per- 
forations reaching to the rear upper or anterior upper part of the periph- 
ery, and finally all perforations of Shrapnell's membrane which always 
extend to the upper margin. 1 

Perforations produced by the loss of the limbus of the drum mem- 
brane together with a part of the bony frame of the tympanic membrane 
are also called marginal perforations. 

1. Central Perforations. 

The large majority of perforations develop more or less distant from 
the limbus. The only exception to this rule are perforations occurring in 
the course of tuberculosis. But perforations occurring in genuine otitis 
media, or in the course of acute infectious diseases are in the very begin- 
ning removed from the limbus. In scarlet fever and typhoid fever I often 
had an opportunity to watch the progress of large perforations from their 
very beginning. The destruction can progress to the margin within the 
first few days only in the severest forms of scarlet fever. The conclusions 
drawn from the majority of these cases have however no bearing on the 
pathogenesis of chronic suppurations of the middle ear, because as before 
mentioned, the general disease soon terminates fatally in these rapid cases. 
New perforations do not usually reach that size, they remain in the inter- 
mediary zone of the tympanic membrane, become round, oval, kidney or 
horseshoe shaped, surrounding the handle of the hammer from below. 
The majority does not surpass two-thirds of the membrane. Sometimes 
we see two perforations in the beginning, one in front, the other in the 
rear, the handle of the hammer forming a bridge between them which may 
remain or later on disappear causing the two to become one. 

These are the usual forms of central perforations which we see after 
years in chronic suppurations, leaving a peripheral zone of the membrane. 
Their size is somewhat larger than in the beginning, partly on account of 
further destructions by temporary granulations of the margins, partly on 



1 Other small perforations reaching the rim of the tympanic membrane at any other place of the 
circumference are observed with some degree of frequency only in otitis media purulenta phthisica 
and will be discussed there. 



Chronic Suppurations. Marginal Perforations. 191 



account of retraction and shortening of the tendon of the tensor tympani 
muscle drawing the handle of the hammer inward to a more or less hori- 
zontal position, and together with it, the whole remnant of the tympanic 
membrane. For the sake of convenience we call those perforations "cen- 
tral" which apparently extend to the anterior inferior or posterior inferior 
margin of the tympanic membrane, as long as the wmole superior periph- 
eral zone together with the enclosed handle of the hammer or its upper 
remnant remain in situ. It is easy to ascertain this at our examination by 
means of the speculum. The lower end of the handle of the hammer is 
not infrequently adherent to the promontory. 

The forms of central perforations thus defined can frequently be 
traced back to acute infectious diseases. 

2. Marginal Perforations. 

Perforations reaching the upper periphery of the tympanic membrane 
or extending partly into its bony frame, and therefore also included in 
marginal perforation are much more varied. 

We know very little as to their pathogenesis since the anamnesis is very 
seldom clear. Of the 578 cases of otorrhoea caused by scarlet fever which 
I saw during 12 years there were only 16 perforations of Shrapnell's mem- 
brane and 17 cholesteatoma. Perforations of Shrapnell's membrane and 
cholesteatoma are however the very forms of disease which always show 
perforations reaching to the margin of the membrane or extending into it. 

Total perforations are most frequently due to some serious general 
disease, especially scarlet fever. 

It is very difficult however to trace the origin of the following forms 
of perforation : the frequent small marginal perforations generally confined 
to the rear upper quadrant, those less frequent perforations reaching the 
periphery in the anterior superior quadrant, but especially the numerous 
defects in Shrapnell's membrane and finally a combination of the three 
forms. In spite of special effort I could never observe the acute develop- 
ment of a perforation in Shrapnell's membrane although I looked for it 
ever so carefully for decades. 

Perforations of Shrapnell's membrane have many characteristical 
points in common. Consumptives are however excepted from this rule as 
in their suppurations, destructions may begin in any part of the tympanic 
membrane, therefore also in the upper periphery. 

An inexperienced person will often have great difficulty in detecting 
perforations in Shrapnell's membrane because the background frequently 
appears white, dry and lustreless, exactly like the surface of the tympanic 
membrane. From this condition of the medial wall of the tympanic cav- 
ity we may easily recognize macroscopically that its lining has changed, 
it has become like epidermis. 

Often none of the margins of the perforation are distinctly visible 
except the margo tympanicus, which protrudes, is often irregular, and us- 



192 Marginal Perforations. 



ually covered with epidermis. The other margins of the perforation may 
be more or less absent because the tympanic membrane together with the 
handle of the hammer have become more or less adherent to the medial 
wall. The tympanic membrane may in this way pass over to the promon- 
tory. The communication between the external meatus and the middle 
ear can only be recognized by a crescent-shaped shadow of the margo 
tympanicus thrown on the inner wall and becoming larger or smaller 
according to the motions of our eyes to and fro. Parts of the inner surface 
of the cavity appear and disappear below the margin, according to the 
position of our axis of vision, as for example the head of the stapes often 
lying bare in the rear upper quadrant, a number of different light reflexes, 
lumps of epidermis or red granulations protruding from the slit. 

Perforations of Shrapnell's membrane situated above the short pro- 
cess and the two upper liminal strands of the tympanic membrane show 
very similar conditions. We can recognize the presence of the perforation 
only at the protruding upper bony margin, if the neck and head of the 
hammer are in situ, as the neck of the hammer appears like a continuation 
of the grayish white surface of the tympanic membrane (compare fig. 
9 on the plate). 

According to the variable size of Rivini's notch the opening may vary 
greatly in extent. In the majority of cases we find the bony rim, which on 
the anatomical specimen has a sharp edge, more or less eaten away, and 
the opening thus secondarily enlarged. It may extend into the anterior 
and posterior superior quadrant of the tympanic membrane by destroying 
the anterior and posterior liminal strands (compare fig. 10 on the plate). 
Sometimes the liminal strands are preserved and there is a perforation at 
the rear upper margo tympanicus, and, though rarely, also in the front 
and upper quadrant. 

We must remember that all these perforations on the upper periphery 
of the tympanic membrane lead into the spaces above the membrane 
(cupula, Hartmann) which we called aditus ad antrum, since they lead 
directly into the antrum. Wherever the perforation is located along the 
upper periphery we must suppose that the disease is mainly situated in 
the aditus and antrum, whence also the secretions originate. 

The structures in the tympanic cavity together with their pathologic 
changes and defects which may become visible in cases of large perfora- 
tions produce such manifold pictures, that they can only be briefly men- 
tioned. 

The lining of the tympanic cavity may appear more or less diffusely 
red and swollen, smooth, or granulating. The upper wall in perforations 
at the upper periphery appears whitish epidermized, if it is not covered 
by depending granulations. The niche of the round window often be- 
comes visible through perforations in the rear lower quadrant while in 
the rear upper quadrant the head of the stapes together with its tendon ap- 
pear. The long process of the incus is comparatively rarely seen, because 



Marginal Perforations. 193 



it is often luxated or lost by necrosis. Perforations in the anterior half 
may open a view into the tympanic ostium of the tube. A horizontal groove 
may become visible in cases where, together with the tympanic membrane, 
the hammer has disappeared, a frequent occurrence after scarlet fever. 
This groove is the end of the semicanalis pro tensore tympani in the tym- 
panum. Parts of the tympanic cavity may be bridged over by scars. A 
thin membrane for example sometimes covers the tympanic ostium of the 
tube and bulges in Valsalva's experiment. 

We sometimes find a formerly large perforation of the tympanic 
membrane entirely or partially closed by a scar which is covered by 
granulations. This condition has often been called myringitis chronica, 
but on account of its origin had better be included in otitis media puru- 
lenta chronica. A similar picture may occur if the very much swollen 
and granulating mucous membrane of the promontory squeezes through 
the opening, etc. 

The secretion in different forms of chronic suppurations of the mid- 
dle ear varies considerably. 

Muco-purulent secretion of the same kind as in acute suppurations of 
the middle ear is only found in central perforations, where the lining epi- 
thelium has preserved its original character. 

In cases presenting marginal perforations at the upper periphery of 
the tympanic membrane, the secretion contains masses of cast-off epi- 
dermis, cheesy masses consisting of different products of decomposition, 
such as cholesterin crystals, fat crystals, masses of saprophytes, etc., like 
those produced in decomposing moist epidermis. These perforations are 
very often combined with more or less extensive replacing of the lining 
of the upper part of the tympanic cavity and its surrounding spaces by 
epidermis. 

A different character of secretion is noticed if extensive granula- 
tions or large polyps are present. In this case it becomes profuse and 
watery, contains little or no mucous and often appears bloody. 

Purely purulent secretion is produced if naked bone is exposed. 

The odor of the secretion is very important for our diagnosis, the 
prognosis and the therapy. 

It is peculiar how long muco-purulent secretion remains without 
odor provided it stays free from other additions, especially decomposed 
epidermis. This can be noticed in acute as well as in chronic suppura- 
tions of the middle ear with central perforations. The secretions for 
example which are found in the external meatus and are mixed with 
macerated epidermis are often very fetid, while after their removal the 
flakes of mucous which are drawn from the tympanic cavity are abso- 
lutely free from smell. This can be frequently observed in removing 
strips of gauze which are still used by some, from the depth of the 
meatus. 

The secretion furnished by large polyps is always abundant, thin, 
fetid and of a disagreeable sweetish odor, 

13 



194 Bacteriologic Findings in Chronic Suppurations. 

The cheesy masses also produced by decomposition of epidermis 
which are removed from the antrum and cells always have a very bad 
odor. This odor is so characteristic that sponging of these spaces with 
a bent probe wrapped with cotton is sufficient to betray by its fetor the 
presence of these masses even though the meatus and the middle-ear may 
appear dry. The smell may become sickening if the suppuration has 
spread into more distant parts. This may be the case in extradural ab- 
scesses, or in abscesses of the brain, or where a perforation occurred 
below the periosteum, either to the outside or below the mastoid process, 
if the pus finds an avenue returning back through the meatus or through 
the fistula to the surface. Such patients are betrayed by their odor as 
soon as they enter a room and it has happened repeatedly that assistants 
hardened by years of similar work became nauseated when an extensive 
abscess of that kind was opened and the pus mixed with gas bubbles was 
evacuated. 

Similar abscesses are betrayed at a distance by these same peculiar- 
ities and may give you an idea of the serious toxic effects produced by 
the gases which are developed by them, and by the diffusion of their 
fluids into the surrounding tissues, the meninges, the brain and the large 
blood vessels. 

We have to say a few words about the bacteriologic findings in chronic 
suppurations of the middle ear. The same pyogenous organisms are 
found as in acute inflammations. They are in pure cultures in fresh acute 
recurrences with muco-purulent secretions that have no odor. As the fetor 
becomes noticeable different kinds of saprophytic organisms appear and 
after the secretion has lasted for a while they increase to immense quan- 
tities of innumerable different kinds. Only some of them can be raised 
and then only unsatisfactorily, as many are anaerobic and their condi- 
tions of life are only partly known. The pyogenous organisms may entirely 
disappear from the secretion and only one or a few kinds of saprophytes 
may remain according to investigations of Stern, if the secretion in the 
meatus decreases, partially dries up and forms crusts. Many chronic sup- 
purations of the middle ear seem to heal spontaneously in this way under 
uncomplicated conditions. Pyogenous organisms may however persist 
and even thrive in putrid foci of the surroundings which lie deeper and 
can not dry up. Abundant streptococci are for example always present 
in septic thrombosis of the sinus, in the walls of the sinus and in the 
thrombus masses even though they may be decomposed. 

Two occurrences are noticed in chronic suppurations of the middle 
ear with such regularity that it does not seem justifiable to call 
them complications as has often been done. They must be considered 
as belonging to the clinical picture, and are firstly, the formation of gran- 
ulations and polyps, secondly, the formation of sclerosed bone in the sur- 
roundings of the diseased spaces. 

The formation of granulations and polyps can be traced as to their 
pathogenesis directly to the lining of the bony meatus. 



Formation of Granulations and Polyps. 195 



Hardly ever does a suppuration of the middle ear, that has been 
neglected for some time, come under our treatment which does not show 
excoriations and even granulations ; in other words, an otitis externa in 
the depth of the external bony meatus, caused by the constant exposure 
to the secretions. Some cases coming from the country and treated by 
unsuitable methods, like warm applications, etc., show the whole meatus 
covered with white diphtheritic membranes which leave an irregular 
granulating surface after they are cast off. The wall of the tympanic 
cavity has the same appearance as far as it can be seen. 

The granulations develop especially well and become independent on 
the free margin of the perforation of the tympanic membrane and in 
marginal perforations on the free bony rim, where it is mostly exposed 
to the passage of pus. On account of their own weight they may cause 
a strangulation of the blood vessels and thereby enlargement of the veins. 
They may quickly increase in size and take all possible forms, club-shaped, 
lobulated, raspberry-shaped, and soon become lined with epithelium 
which may be ciliated on the inside and epidermised on the outside. 
Young polyps consist of granulation tissue, older ones may become fibro- 
matous, sometimes containing myxomatous parts and even, though rarely, 
bone. They sometimes become unusually large after years of existence 
and protrude from the external meatus with a club-shaped end which 
may grow as large as a cherry. This end has a lining of dry epidermis 
and protrudes from the external meatus. The pedicle becomes very thin 
and reaches in the depth to the circumference of the tympanic membrane. 
The root of such large polyps is usually directly inside of the rear upper 
limit of the sulcus tympanicus. Smaller polyps very often develop in 
marginal perforations of the upper periphery and project downward from 
the slit leading to the upper spaces of the middle ear like a theatre cur- 
tain. The removal by means of the curette shows that they usually orig- 
inate from the protruding margo tympanicus, from the lateral wall of the 
aditus or from remnants of the ossicles. 

Moos expressed the view that the majority of polyps originate from 
the inner wall of the tympanic cavity. It was widely propagated but does 
not at all coincide with my experience. Granulations arising from a 
broad base on the promontory, quickly recurring after removal, are com- 
paratively rare. They usually correspond to a fistula in the bone or indi- 
cate extensive necrosis of the wall of the labyrinth. 

The fact that granulations and polyps develop regularly on bare 
suppurating surfaces indicates that they have a certain physiologic value 
for regeneration. Every loss of substance of the normal organisms is re- 
paired by formation of granulations. Our organism has no other mech- 
anism at its disposal for the removal of foreign bodies, sequesters, etc., 
than the formation of an elastic soft dam of granulations all around them. 
The foreign body is removed by increased pressure from the inside which 
pushes it gradually to the outside and finally expels it without our help. 



106 Sclerosis of the Bone. 



An organism lacking this power of regeneration succumbs helplessly to 
the harmful influence to which it is constantly exposed. This we shall 
see plainly in treating the subject otitis purulenta in patients suffering 
from consumption and other serious diseases, who lack partially or com- 
pletely this formation of luxuriant granulations which constitute an un- 
failing reaction of the normal organism against correspondingly strong 
inflammatory irritations. 

The granulations become plainly pathologic however, and have to be 
removed as soon as their growths become independent to some degree, 
when they organize and keep on growing independently like tumors. 

In radical operations, required in old serious suppurations of the mid- 
dle ear, sclerosed bone is always found extending far into the surround- 
ings of the antrum. The examination of a great number of temporal 
bones affected with slight forms of old suppurations of the middle ear, 
which were however accidental findings and independent of the fatal 
course, reveals the fact that in these cases also sclerosis of the bone is 
present to a greater or less extent. 

The process of sclerosis of the bone consists in the formation of solid, 
exceedingly hard bone in place of the pneumatic spaces and cavities con- 
taining bone-marrow which surround the antrum. Only a few small cells 
are preserved far away from the antrum, together with a thin peripheral 
layer of spongy substance in the mastoid process. 

Here again consumptives show an exception. I never saw sclerosed 
bone in these patients notwithstanding many years of serious suppuration 
of the middle ear. The contrary is the case, an abundance of large and 
small pneumatic cells is the rule in consumptives. 

The casual post-mortem findings after acute suppurations of the mid- 
dle ear, which had healed a number of weeks previous with closing of the 
perforation of the membrane, gave us the explanation for the develop- 
ment of the process of sclerosis of the bone. The pneumatic spaces, 
except the tympanic cavity and the antrum, were filled to a large extent 
by a tough, pale red tissue, representing evidently a later state of the proc- 
ess of apposition of bone studied by Schicbe, which finally terminates in 
the complete ossifying of the spaces. 

This process was also considered by Steinbrilgge in his "pathologic 
anatomy of the organ of hearing" as a protective measure of the organ- 
ism, which tries to create more favorable conditions for the course of 
prolongated suppurations by diminishing the size of the spaces and sim- 
plifying their arrangements. Other authors however considered this 
hyperostosis as a serious complication endangering life by interfering 
with a perforation to the outside and thereby favoring one to the cavities 
in the skull. They forgot entirely that in chronic suppurations (choles- 
teatoma) a gradual enlargement of the external opening at the margo 
tympanicus, leading from the meatus into the diseased spaces, progresses 
step by step with the process of sclerosis of the bone. The cavity which 



Chronic Suppuration of the M. E. with Central Perforation. 197 

has sclerosed walls can in the course of years acquire a sufficiently large 
opening towards the external meatus, so that on examination through 
the meatus the same picture is seen as though a radical operation had been 
performed. The focus of the disease healed spontaneously and remained 
dry in a large number of cases, which I observed, by enlarging the en- 
trance until the whole focus formed a simple deep groove. This process 
of healing accomplished by nature deserves admiration, but we never dare 
rely upon it on account of the possible interference of incidents dangerous 
to life. A constant careful control of such cases is necessary. 

A. Chronic Purulent Inflammation of the Middle Ear with 
Central Perforation of the Tympanic Membrane. 

The course of otitis media purulenta chronica with a central perfora- 
tion is comparatively simple in an otherwise healthy organism. 

The suppuration which usually dates back to some acute infectious 
disease during childhood, lasts with frequent recurrences for years and 
tens of years if left to itself. In other cases it appears to be healed for 
months and even years when suddenly it begins anew as the consequence 
of some injurious influence reaching the middle ear. The entrance of 
water into the middle ear is especially harmful either through the meatus 
or through the tube, in diving, swimming, or if nasal douche is wrongly 
applied. Germs of infection may furthermore be carried into the tym- 
panic cavity by all kinds of instruments introduced into the depth of the 
meatus for the purpose of cleaning. The pyogenous and saprophytic 
germs which are always attached to the walls of the meatus are innoc- 
uous as long as they remain dry. Serum furnished by some minute inju- 
ries produced in cleaning, furnishes the moisture necessary for their 
growth. Acute catarrhs of the nose are a frequent cause for constant re- 
currences of suppuration, as long as a permanent occlusion of the tym- 
panic ostium of the tube has not formed. This we sometimes see after 
suppurations lasting for years, produced as a natural protection against 
these invasions. Children especially are addicted to acute nasal catarrh 
and its propagation through the tube, which, on account of the perforation 
in the tympanic cavity, opens so much more easily at each blowing of the 
nose. Thus the muco-purulent secretion from the lining of the middle- 
ear can never cease, but continues in varying quantities. 

I have shown you the consequences of persistent discharge from the 
ears, if it is not treated. The epidermis of the tympanic membrane and 
meatus becomes macerated, then excoriated, later on granulations and 
polyps will form on the most exposed edges. Polyps may develop in 
simple central perforations as frequently as in marginal perforations, if 
they are not treated. After the removal of polyps which were so large 
that they protruded from the external canal I repeatedly found a simple 
suppuration from a central perforation which stopped definitely after a 
few days of rational treatment. 



198 Treatment of Chronic Suppuration zvith Central Perforation. 



It is peculiar that polyps large enough to fill the whole meatus never 
cause symptoms of retention although they may exist for years. I saw 
signs of general sepsis however in rare cases where the external part 
became greenish discolored under the influences of saprophytes. 

Simple forms of chronic otitis with central perforations hardly ever 
lead to necrosis of bone in an otherwise healthy organism except in cases 
where long lasting harmful influences create special predispositions to it, 
as for example a piece of cotton which became lost in the tympanic cavity 
causing the production and retention of fetid secretions. 

We shall discuss the rare result of general sepsis in cases which 
developed no sclerosis of the bone in the surroundings of the main spaces 
of the middle ear in connection with other complications. 

In a large number of cases where polyps were not formed the sup- 
puration gradually ceases spontaneously. The pyogenous organisms dis- 
appear and the secretions containing only saprophytes dry up, forming 
crusts which adhere to the tympanic membrane. The crusts may be 
gradually carried outside by the mode of growth of the epidermis pecu- 
liar to the meatus (compare page no). The perforation of the membrane 
may at the same time become concentrically smaller from granulations 
growing all around its margin, and may finally close, forming a granu- 
lating surface covered later on by a scab. One by one these scabs mi- 
grating over the surface of the membrane and the meatus form a chain 
like a rosary reaching as far as the cartilaginous meatus. The migra- 
tion is the same as in extravasations of blood. 

Large and old perforations extending over two-thirds or more of 
the membrane rarely close during the time we watch them. We shall 
see however in speaking about residues how frequently and in how ex- 
tensive a measure the formation of scars takes place after a longer lapse 
of time. 

Treatment of Otitis Media Purulenta Chronica with 
Central Perforations. 

The favorable influence of antisepsis becomes much more apparent 
in the treatment of chronic suppurations of the middle ear than in acute 
cases. The conditions are different and simpler in many regards. 

In acute suppurations there is a complicated system of cavities with 
a small perforation in the membrane closed by a valve-like mechanism. 
In chronic suppuration often nothing is left of the cavities of "the middle 
ear but the tympanic cavity, the aditus and the antrum which are acces- 
sible to a strong jet from the syringe through a usually large opening 
in the membrane. In acute suppurations there are often very virulent 
pyogenous organisms spread in the lining and in the contents of a compli- 
cated system of cavities, with which the organism, without any possible 
artificial support from the outside, only with its own means of protec- 



Treatment of Chronic Suppuration with Central Perforation. 199 

tion, has to cope. In chronic cases we have mainly saprophytes which are 
always accessible to that antiseptic which alone can be used in the middle- 
ear in sufficient quantity and concentration for any length of time, 
namely, boric acid in powder form. Its effect is always telling, provided 
the anatomic conditions permit us to reach every part of the diseased 
cavities. These facts are proved by the numerous cases of fetid suppura- 
tion of the middle ear lasting for years with and without interruption, 
which were definitely cured by one or a few careful antiseptic treatments. 

The antiseptic treatment is carried out in chronic suppuration in the 
same manner as in the acute. 

The injection of 4 per cent warm boric acid solution ought to be 
made with some force in a broad jet in order to reach all the walls. 
Care is necessary in cases of considerable deafness, especially where it 
developed a short time previous, on account of the possibility of de- 
struction of the windows. 

The injection is always succeeded by inflation of air by means of 
Politzer's method if the tube has not grown shut, in order to evacuate 
the secretion and the fluid outward. The consequent drying out with a 
probe wrapped with cotton must be extended over the tympanic cavity 
through the large opening and cannot be done too carefully or too often. 

The final insufflation of boric acid powder is done as in acute suppu- 
ration but more force may be used, in order to reach the drum cavity as 
much as possible through the large opening. 

A loose piece of cotton is inserted not deeper than the cartilaginous 
meatus for protection of the ear. 

This treatment is repeated every day in the beginning, later on as 
often as secretion is present. The boric acid powder remains in the 
depth if the secretion has ceased. 

The treatment with boric acid stopped the fetor in all cases of sup- 
puration of the middle ear which were accessible to the jet of the syringe 
throughout the whole extent of the diseased cavities. It never produced 
irritation and I had therefore no reason to deviate from it. However, 
some, though insufficient experience was acquired as to the effect of other 
antiseptics like aqua hydrogeni hyperoxydati (peroxyd of hydrogen) 6 
per cent, formaline in 1 per cent, resorcin in 4 per cent solutions ; they 
were recommended by other authors and used the most extensively. 

Solutions of 3 to 10 per cent nitrate of silver are used by Schwartze 
if the lining of the middle ear is succulent and swollen, while Politzer 
uses instillations of dilute and absolute alcohol if it is granulated. 

Every circumscribed growth, be it ever so small, ought to be re- 
moved by means of the snare. We use Wilde's instrument armed with 
pliable flower wire (compare fig. 63, page 177). The many changes 
which have been made in this instrument are not improvements in my 
estimation. It is not necessary to cauterize the place where granulations 
have been removed according to my experience. 



200 Treatment of Chronic Suppuration with Central Perforation. 

Small polyps which are unfavorably situated for removal by means 
of the snare are cauterized with a little pearl of nitrate of silver melted at 
the point of a probe. The probe end is moistened for the purpose and 
dipped in pulverized nitrate of silver. Sufficient powder remains on the 
probe to form a little pearl if it is held in the flame of an alcohol lamp for 
a few seconds. Granulations attached broadly to the outside of the 
drum membrane, often seen in cases where large perforations gradually 
close, are better left untouched. 

The use of caustics in the middle ear whose effect reaches far into 
the depths, especially the galvano-cautery, must be cautioned against, as 
we can not always measure their effect accurately. 

The galvano-cautery snare however can not always be avoided in 
removing very large polyps reaching to the entrance of the meatus, 
as they sometimes consist of very tough tissue. The removal is usually 
not successful at the first attack, but is accomplished piecemeal. The 
pedicle, usually consisting of softer tissue, can be cut with the cold snare. 

I have never found a necessity for other operative interferences in 
chronic suppurations of the middle ear with central perforations, except 
in those extremely rare cases of general sepsis after acute recurrences 
(compare later on). 



LECTURE XXL 

B. Chronic Purulent Inflammation of the Middle Ear 
with Marginal Perforation. 

Perforation of the Membrana Shrapnelli Cholesteatoma. 

Gentlemen : — The following two points lead me to the conclusion 
that perforations in the upper periphery have a different etiology from 
central perforations. The position of the perforation is in places where 
we never see a perforation in otitis following acute infectious diseases. 
Secondly., the statistical results of careful anamnesis especially carried 
out for decades in this direction, point equally to a different origin. 

In 1879 m y attention was drawn to the frequent occurrence of per- 
forations of Shrapnel? s membrane because of their different response to 
boric acid treatment. They had remained nearly unnoticed until then, 
and I directed my investigations especially towards their frequency of 
occurrence, their etiology, and their accompanying symptoms. 1 

Perforations in Shrapnell's membrane are found in 1.2 per cent of 
all diseases of the ear, and in 6 per cent of all chronic suppurations of 
the middle ear. Only 12 per cent were children. They are found 
rather frequently in both ears (16.8 per cent) or together with choles- 
teatoma of the other ear. 

I never, as repeatedly stated, saw a perforation in Shrapnell's mem- 
brane form in the course of a genuine or a secondary acute suppuration 
of the middle ear. 

The direct continuation of the epidermis of the tympanic membrane 
to the white lining of the cavity can almost always be seen, if granula- 
tions do not interfere. Large masses of epidermis can in the large ma- 
jority of cases be removed from the cavity by means of direct injections. 

The frequent occurrence of symptoms pointing to a simultaneous 
occlusion of the tubes, lasting for a long time, struck me very early. 
For example, retraction of the membrane is often found in both ears to- 
gether with atrophy of the membrane, deafness which was considerably 
improved by inflation of air, adenoid vegetations, etc. A relation be- 
tween occlusion of the tubes and a perforation of Shrapnell's membrane 
as cause and effect suggests itself. Remembering on the one hand the 



1) Ueberschau liber den gegenwartigen Stand der Ohrenhlk. Wiebaden Bergmann, 1895, page 116. 

201 



202 Perforation of Shrapnell's Membrane. 

high degree of atrophy and thinness from expansion which often take 
place in the tympanic membrane after years of occlusion of the tubes, 
and on the other the frequent recurrences of acute inflammations, we 
can not be surprised that the membrane yields to the outer air pressure 
which constantly weighs upon it, and that it tears at the very membrana 
flaccida, which lacks the solid support of the regularly arranged fibres of 
the membrana propria. Succeeding purulent inflammation and granula- 
tions on the edges, etc., result in their uniting with the wall of the small 
space above the membrane, thus forming the bridge over which the epi- 
dermis of the tympanic membrane and of the walls of the meatus may 
grow directly into the aditus and the antrum. This occurrence makes 
the opening a permanent one and at the same time explains the change 
into epidermis, which we notice in the lining of the cavity. 

Similar processes may take place in marginal perforation on the an- 
terior and posterior part of the superior periphery of the membrane, pro- 
vided that the membrane has become very atrophic at those places. Only 
the small perforations showing extensive synechias of the margins with 
the inner wall of the tympanic cavity can be explained in this manner. 

The numerous total perforations which often lead to formation of 
epidermis in the middle ear usually originate from former serious acute 
infectious diseases. The destruction extending to the upper part of the 
margo tympanicus leading to the antrum and involving it, opens the 
avenue for the advancing growth of epidermis into and over the cavities 
of the middle ear. The lining of the tympanic cavity is often found cov- 
ered with granulations, or evenly swollen and red throughout its whole 
extent, while the epidermoidal change upward from the isthmus leading 
to the aditus ad antrum, is visible through the opening in the tympanic 
membrane. In other words the epidermisation of the aditus and antrum 
progresses more rapidly and earlier than in the tympanic cavity. 

Holes in the upper bony wall of the meatus left after serious proc- 
esses in the bone, and healed with expulsion of sequesters, may act as 
another avenue through which the formation of epidermis progresses 
into the aditus and antrum. 

The epidermisation of a granulating surface, occurring as just de- 
scribed, in the middle ear, through formation of gaps is a process of heal- 
ing identical with that which we observe in the repair of every loss of 
substance on the surface. Schwartze calls the continuation of the epider- 
mis of the meatus into the tympanic cavity and the cells of the mastoid 
process the "surest protection against recurrence of the suppuration/' 

The epidermisation of the lining of the middle ear becomes danger- 
ous often enough because its road into the cavities leads through narrow 
openings and slits. The cast-off scales of epidermis can not be absorbed 
by the walls as the secretions of a simple suppuration are, but as dead 
and retained masses cause a continual irritation of the walls, thus inciting 
renewed and increased production of epidermis. 



Cholesteatoma. 203 



This is the origin of the frequent disease of the middle ear called 
"cholesteatoma." 

v. Trocltsch, by means of his post-mortems, established the great 
frequency of cholesteatoma of the antrum mastoideum, and this keen in- 
vestigator also recognized the great danger involved (fig. 65). 

Filling either the aditus alone or also the antrum throughout its 
whole extent, we find solid masses of epidermis. They may be decom- 
posed towards their center from the extremity which communicated 
with the outside. Their periphery, which in the rear is bag-shaped, is 
arranged in regular superimposed layers. 

An enlargement of the bone cavity in all directions and a shrinkage 
of the margins takes place if sufficient time is allowed for the develop- 
ment of large masses from the constantly repeated casting off of new 
scales of epidermis. Thus these masses of epidermis may break through 
the bone into the external meatus, or under- 
neath the periosteum of the outer surface of 
the mastoid process, into the labyrinth, or 
through the base of the skull underneath the 
dura. No trace can be found of the bony 
septa between the cells after this enlargement 
has taken place. The masses of cholestea- 
toma arranged like the layers of an onion (com- 
pare fig. 65 ) are situated in a bone cavity with Fig. 65. 
smooth lining and only flat excavations. The Cholesteatomatous masses 

walls are sclerosed throughout. removed by means of 

. radical operation in the 

Whenever they become moist the masses living, natural size. 

of epidermis which are accessible from the out- 
side through the opening in the tympanic membrane, undergo a rapid 
putrid decomposition. They in turn act as foreign bodies, causing the 
formation of granulations in their vicinity, suppuration, and often caries 
of the bony wall and of the ossicles which they surround. 

The manifold deficiencies in the bony walls caused by the excentric 
growths of the masses of epidermis create avenues for the spreading of 
the septic purulent processes to the meninges, the large blood vessels, 
and the brain. 

Cholesteatoma amount to 2.2 per cent of all diseases of the ear ; and 
to nearly 11 per cent of all chronic suppurations of the middle ear, if 
we include also the perforations of Shrapnell's membrane which almost 
without exception show gathering of epidermis in the aditus and antrum. 

The youngest child whom I operated for gathering of epidermis in 
the antrum was three years old. The large majority of patients observed 
suffering from cholesteatoma are between 10 and 40 years. The begin- 
ning of the suppuration which is the cause of the whole process usually 
dates back to childhood. 




204 Cholesteatoma. 



The defects which become visible at our examination with the specu- 
lum often extend far beyond the tympanic membrane, more or less into 
the upper and rear bony wall of the meatus. Their size varies from a 
small peripheral addition to the upper pole of the perforation of the 
membrane, to a complete absence of the rear upper bony wall of the 
meatus, so that both the aditus and the antrum are open toward the 
meatus throughout their whole extent. There is sometimes, besides the 
extension of the perforation of the membrane, an isolated gap or fistula 
in the outer part of the meatus, and between both there is a bridge of 
soft tissues formed by that part of the lining of the meatus which re- 
mained intact. 

The formation of granulations and polyps is found extremely fre- 
quently combined with cholesteatoma, namely in half of the cases which 
I saw. Their location in the region of Shrapnell's membrane, or protrud- 
ing from the rear upper periphery, indicates the presence of cholestea- 
toma. 

The openings in Shrapnell's membrane lead directly into the aditus, 
because the ligaments of the head of the mallet and incus, and often the 
heads themselves have partially or entirely disappeared from pressure. 
The upper spaces containing the cholesteatoma are usually separated 
from the tympanic cavity below, which explains why no noise of perfora- 
tion can be produced by inflation of air. The tube is often closed by 
granulations, or it has grown shut in the region of the ostium tympani- 
cum. 

The subjective symptoms of cholesteatoma may remain latent for 
many years, as the secretion may cease temporarily or amount to so little 
that nothing but a dry crust is formed in the depth. 

Only one-third of all cases which I compiled complained at times of 
headache, dullness in the head, melancholy, etc. 

Dizziness usually occurs only during syringing. A serious attack of 
dizziness can be produced by sponging with the probe wrapped with cot- 
ton if the region of the horizontal semicircular canal is exposed by the 
perforation. The dizziness may reach such a degree that the patient is in 
danger of falling from the chair. We may presume that in such cases 
the endosteum of the semicircular canal is exposed through a perfora- 
tion in the bone. 

The partial evacuation of masses of epidermis sometimes occurs 
spontaneously and is then accompanied by very great pain and swelling 
of the meatus. Facial paraylsis is sometimes noticed during this process, 
but usually disappears after a few months. 

The chorda tympani is comparatively frequently affected in chronic 
suppurations of the middle ear. The consequence is paralysis of taste 
in the anterior two-thirds of the same side of the tongue as the af- 
fected ear lies. The chorda is sometimes exposed in the tympanic cav- 
ity, and the patients at each touch feel a pricking, stinging sensation on 



Cholesteatoma. 205 



their tongue, and a burning if touched with some warm object (syringo- 
scope). Injury to the chorda can not always be avoided in extraction 
of the ossicles and in radical operation. The chorda tympani, just as 
the facial nerve, is able to regenerate very extensively. The loss of this 
function is so unimportant that it is hardly ever noticed by the patient. 
We use four different substances for the examination of taste, sweet, 
sour, salt and bitter. These are applied to the half of the tongue which 
we wish to examine, having previously dried it. 

Patients complain of subjective noises only very exceptionally. 
They are rarely observed in chronic suppuration of the middle ear. 

The power of hearing varies greatly in perforations of Shrapnell's 
membrane as also in cholesteatomata originating from some other cause. 

Twenty per cent of my patients with perforations in Shrapnell's 
membrane understood whisper at a distance of from 2 meters to the 
length of a room and more ; while of those with cholesteatoma this hear- 
ing-distance was found only in 7 per cent. 9 per cent of the first class of 
cases understood whisper indistinctly close to the ear, and of the latter 
class 34 per cent. 

Among patients who understand whisper indistinctly are classed 
also those who have lost their hearing entirely, which condition is ascer- 
tained by examination with the continuous series of sounds in air conduc- 
tion (I confined my examinations to the test of the sound a' in the mid- 
dle of the series). 

A rapid disappearance of the power of hearing during our observa- 
tion, combined with the appearance of dizziness and vomiting, indicates 
that the suppuration has invaded the labyrinth, which makes the prognosis 
very serious. 

As in all diseases of the sound-conducting apparatus, prolongation 
of bone conduction above the normal (Schzvabach's test) and prolonga- 
tion of bone conduction -compared with air conduction (Rinne's test) ex- 
ists together with the loss "of hearing for more or less of the lower end 
of the series of sounds, as long as the labyrinth is intact. 

The diagnosis of cholesteatoma is established by means of examina- 
tion with the ear speculum and by removing masses of epidermis from 
the upper spaces of the middle ear. 

As to the prognosis of these diseases, though only if they are not 
properly treated, the old phrase of Wilde is still valid in its every sense : 
"We are never able to tell how, when or where a suppuration from the ear 
will end, nor where it may lead to." 

Treatment of Otitis Media Purulenta Chronica with 
Marginal Perforations. 

The treatment of chronic suppurations with marginal perforations 
is more difficult than of those with central perforations, although the 
form of the diseased spaces is much simpler than in the second class of 



206 Treatment of Chronic Suppuration with Marginal Perforation. 

cases, because all pneumatic cells except the aditus and antrum have been 
filled by eburneous bone. One reason is the narrowness of the opening, 
especially in perforations of Shrapnell's membrane; another is the close 
adhesion of the scales of epidermis to the walls of the cavity, which is 
often excentrically enlarged. 

We use special metal tubes, called antrum tubes, of different shapes 
and curves in order to throw the jet directly against the masses we in- 
tend to remove (compare fig. 66). They were first described by 
Arthur Hartmann. They are connected with the syringe by means of 
a rubber tube and are inserted under the control of the speculum into the 



ti'ffp 




Fig. 66. 
Antrum tubes of different width and different curves. 



perforation in Shrapnell's membrane, or upward from the tympanic cav- 
ity into the slit opening into the aditus and antrum. We are sometimes 
able to remove, by means of these injections, surprisingly large masses of 
semi-solid cheesy products of decomposition, and finally thick scales of 
white epidermis arranged like onion peels. To reach them by an ever 
so strong straight jet through the meatus would have been an utter im- 
possibility. W r e use 4 per cent boric acid solution of 98.6 F. for the 
injections in order to avoid the dizziness which they easily produce. 

The solution must however be heated to 105 degrees before it is 
filled into the syringe in order to obtain the right temperature. 

Politzcr's method is applied if the tube has not grown shut. 

Special care must be given to the drying of the cavity. Probes 



Treatment of Chronic Suppuration with Marginal Perforation. 207 



wrapped with cotton are bent to suit the case (compare fig. 67) and are 
repeatedly inserted far into the cavity. 

The results of treatment have improved decidedly with the practice 
of inflating boric acid powder directly into the previously carefully dried 
cavity. This is accomplished through a dry antrum tube similarly to the 
injections of fluid. Instead of pure boric acid a mixture of salicylic acid 
and boric acid powder (1 to 4) may be used in order to induce a more 
rapid expulsion of thick peripheral layers of epidermis from the cavity. 
It is quite possible that during this procedure some pyogenous germs, 
products of decomposition and even tubercle bacilli, are dispersed into 
the surrounding air. It is therefore advisable for the surgeon to use 
some kind of a protection, either a glass diaphragm or a cloth protect- 
ing the face, as some serious experiences of my assistants taught me. 





Fig. 66A. 

Bulb with rubber tube in connection with 
the antrum tube. 



Fig. 67. 

Probe used in drying out the aditus 
and antrum. 



Very frequently we have to remove granulations and polyps in mar- 
ginal perforations. They protrude downward into the slit, and curettes 
must often be used besides Wilde's snare. The curettes (compare fig. 
68) are inserted beyond the free margo tympanicus, and with some gentle 
handling we will readily succeed. Many polyps which could not be seen 
may be removed from distant parts of the cavity by means of the jet from 
the antrum tube, thus stopping a suppuration that has lasted for a long 
time. 

In cases where a fistula has developed in the meatus, leaving nothing 



208 Treatment of Chronic Suppuration with Marginal Perforation. 

of the upper bony wall of the meatus but a bridge of soft tissues, the 
antrum can be easily made accessible by cutting the bridge. 

Sometimes the suppuration remains fetid in spite of careful treat- 
ment continued for months by means of the antrum tube and the re- 
moval of polyps. This state of affairs proves that the entrance to the 
cavity is inadequate, and that a part of it can not be reached by the jet 
of the syringe. The indication is therefore to make the focus of the dis- 
ease accessible by means of an operation. 

We may try to enlarge the entrance to the cavity by removing the 
hammer through the meatus (Kessel), if the power of hearing is already 
defective. I do not deem it advisable however to remove the incus also. 
Moreover its position places it beyond our vision, so that we can not 
guide the incus hook with our eye. 

The radical operation, that is the persistent opening of the aditus 
and antrum by removing their external wall as Zaufal and Stacke ad- 
vised it, has to be performed when the fetid suppuration persists after 
the removal of the hammer. 




68. 

Curettes for the removal of granulations from the aditus and antrum. 

Painful swelling with consecutive fluctuation of the soft tissues of 
the pars mastoidea and the formation of fistula in the surroundings of 
the ear in the presence of cholesteatoma, are indications for a prompt 
operation. 

Plastic operations of the external meatus must be resorted to, if a 
very much excentrically enlarged cavity is found. Sometimes it is neces- 
sary to leave a temporary or even a permanent opening behind the auri- 
cle in order to facilitate the after-treatment and the control of the whole 
cavity later on. 

The meatus enlarged by operation suffices however for the after- 
treatment if the antrum is not excentrically enlarged. 

The chain of ossicles is often intact in perforation of ShrapnelVs 
membrane. The operation under such circumstances must spare the os- 
sicles and thereby preserve a good deal of the function of the ear (com- 
pare the plate of pictures of the tympanic membrane fig. 14). 

The details of the technic of the extraction of the hammer, and of 



Treatment of Chronic Suppuration with Marginal Perforation. 209 

the radical operation, will not be described here, since both operations 
require the hands of a specialist. 

These patients need the attention of a physician seyeral times a year 
for the rest of their lives, because scales of epidermis may gather anew 
in some recess of the cavity, and cause formation of granulations and 
purulent secretion, no matter how carefully the cavity has been cleaned 
out either with or without operation, and despite the fact that the suppu- 
ration may have ceased for months and years. 

The entrance of water into the cavity in bathing, etc., must be very 
scrupulously avoided. 



H 



LECTURE XXII 

Suppurative Inflammation of the Middle Ear 
in Consumptives. 

Otitis Media Purulenta Phthisica. Caries and Necrosis 
of the Middle Ear. 

Gentlemen: — Caries can be clinically differentiated from the process 
of absorption of the bone as described in acute empyema of the mastoid 
process, and from absorption in cholesteatoma, by the following pecu- 
liarities : In caries certain parts of bone are stripped of their soft tissues 
and lack nutrition; the process of dying away of the bone progresses 
even under favorable local conditions, as for example after operative ex- 
posure of the whole focus. It terminates with the demarcation and 
expulsion of a sequester (necrosis). 

Caries and necrosis in the temporal bone, as also cholesteatoma, pre- 
sent themselves in the large majority of cases not as independent dis- 
eases but as incidents of the suppuration of the middle ear taking an ab- 
normal course. 

The causes for this abnormal course are according to our experience 
either serious general diseases, considerably decreasing the power of re- 
action of the organism, or long lasting and serious local disturbances in 
the spaces of the middle ear. 

We saw for example local necrosis of bone occurring after acute 
suppurations of the middle ear in the course of some serious acute exan- 
thema. 

The following disease must be considered a typical example of the 
influence of a cachectic general organism on the local process. 

Otitis Media Purulenta of Consumptives. 

This form of otitis is found in 0.7% of all ear patients and in 44% 
of chronic suppurations of the middle ear. 

Children are represented by very small numbers namely 5.5% com- 
pared to 94.5% of adults. This number is probably too small as my 

210 



Otitis Media Parulenta Phthisica. 211 

statistics of consumptives with suppuration of the middle ear were com- 
piled chiefly from an infirmary which does not admit children. 

They attack both ears more frequently than all other forms of sup- 
puration of the middle ear, namely in 32.3%. 

The perforation of the membrane and the suppuration may occur 
very acutely under our eyes. It is however characteristic for otitis me- 
dia purulenta phthisica that all other objective and subjective symptoms 
of inflammation like redness, swelling, pain and tenderness are as a rule 
more or less absent. The destruction in spite of this nearly complete 
absence of symptoms progresses with the rapidity that we usually see 
only at the hight of the most serious acute infectious diseases. The 
perforation is large from its first appearance and frequently located in 
unusual places, for example in the anterior half, or in the anterior su- 
perior quadrant, or on the margin of the membrane. It sometimes 
enlarges from day to day, other perforations develop (compare the plate 
fig. 11) and it frequently destroys in a short time a large part or the 
whole of the tympanic membrane. 

The findings at the post-mortem correspond with these extensive 
destructions observed on the living. Frequently the ossicles are partially 
loosened in their connections with each other and with the walls, or they 
are eliminated altogether. The tendons of the muscles are decomposed. 
The bone in many parts of the walls of the middle ear lies uncovered, 
and contains at an early period loose sequesters of different dimensions. 
The windows of the labyrinth and their bony surroundings are not 
rarely implicated in the destruction. The most rapid decay of all struc- 
tures of the middle ear which I ever saw was at the time of the tubercu- 
lin treatment (1890) in a patient who was under the influence of a con- 
tinual use of tuberculin. 1 

Occasionally after the process has lasted for a long time, large se- 
questers are found, extending over the whole mastoid process and be- 
yond. 

The difference between otitis media purulenta of consumptives and 
all other forms of acute and chronic suppurations of the middle ear be- 
comes even more striking from the view point of pathology as evidenced 
in the macroscopic appearance of the tissues, than from the clinical feat- 
ure of the uninterrupted rapid progress. The tissues attacked by the 
disease show macroscopic ally almost no reaction against the destroying 
influences. All processes of protection and healing with which we be- 
came acquainted in acute and chronic suppuration of the middle ear in 
the otherwise healthy organism are almost entirely absent here. We see 
instead of the big swelling which extends over the whole lining of the 
middle ear in acute otitis media purulenta, how this lining as also the 
tympanic membrane, succumbs to the disease in some places. A few 



i Ueber das Verhalten der im Verlauf von Phthisis pulm. auftretenden Mittelohreiterungen 
unter dem Einfl. d. Koch'schen Behandlung. Deutsch Arch. f. klin. Med. vol. 47. 



212 Otitis Media Purulenta Phthisica. 

small granulations appear here and there in the immediate vicinity of 
places where a sequester forms. They are totally inadequate for the 
expulsion of the sequester. 

A new formation and eburnisation of the bone filling the pneumatic 
cells, thereby simplifying and limiting the focus of the disease, as is seen 
in the healthy organism, was never observed in the surroundings of the 
suppuration, even in cases where the process lasted for a comparatively 
long time. 

The advancing growth of epidermis as a final process of healing of 
the cavities which have lost their lining, never takes place as completely 
as in the normal organism. 

The presence of Koch's bacilli alone can not be accepted as a suffi- 
cient explanation of the more or less total absence of all processes of 
protection and regeneration in the majority of cases of otitis media puru- 
lenta phthisica. Tubercle bacilli at least in the secretion are not found 
as frequently as we should expect, if that rapid decay of tissue were 
entirely due to them. They are even entirely absent in the secretions of 
some serious cases during their whole course. Another fact contradicts 
even more decidedly the exclusive dependence of this clinical picture 
upon the presence of tubercle bacilli. There are two forms of suppura- 
tions of the middle ear where the organism has not lost its normal power 
of reaction and where we always find a considerable number of tubercle 
bacilli, namely the caries and necrosis in the ear of scrofulous children, 
and the formation of the fibrinoid exudation. Both processes have noth- 
ing in common with the clinical picture which I just described as otitis 
media purulenta phthisica, except the presence of tubercle bacilli. They 
will be discussed separately. 

In some cases the general disease in the lungs and in other organs 
is so slightly advanced that at the time a phthisic suppuration of the mid- 
dle ear sets in, no pronounced symptoms have appeared. It may even re- 
main stationary or heal to a certain extent. Those are the rare cases of 
phthisic suppuration of the middle ear which may be cured and in which 
a small perforation of the tympanic membrane may even close. 

The course of the large majority of cases is however marked by the 
uninterrupted progress of the destruction. 

A few additional points make the clinical picture more characteristic 
for our diagnosis. The perforation of the tympanic membrane becomes 
larger and other perforations appear (compare fig. n on the plate). 
The discharge is purulent and usually fetid, the tubes are wide open so 
that the fluid in syringing runs through them in a stream, the bone of the 
wall of the promontory soon becomes uncovered and rough, and finally 
the power of hearing decreases greatly in a very short time. 

There is no other kind of suppuration of the middle ear which so 
frequently shows complete loss of hearing. The ossicles are loosened 
from their connections, the tendons of the muscles are decayed, even the 



Mastoid Tuberculosis of Children. 213 

membrane of the round window and the ligamentum annulare succumb 
to the destruction, and the suppuration progresses into the labyrinth. 

Swelling, formation of granulations in the meatus, and intense pain 
may occur later on, when large sequesters have formed and become par- 
tially movable. It is however peculiar that in spite of the frequent 
panotitis the compact bony capsule of the labyrinth, or some parts of it, 
are never expelled as a whole. 

A consecutive meningitis is comparatively rarely observed. 

Paralysis of the facial nerve is of frequent occurrence. 

Fatal hemorrhages from the carotid artery caused by luxation of a 
sequester comprising its bony sheath were observed most frequently in 
phthisic suppurations of the middle ear. 

It is surprising how long the dura and the external wall of the sinus 
can resist the suppuration which takes place on their surface. Sinus 
phlebitis, suppurative leptomeningitis, and abscesses of the brain rarely 
cause death. The fatal issue is usually brought about not directly by the 
disease of the ear but by the general disease. 

Mastoiditis Tuberculosa of Children. 

Tuberculosis of the middle ear in children, though presenting the 
same characteristic progressive decay of the tympanic membrane with- 
out the formation of granulations, is observed but exceptionally, and 
then only in older children. 

A somewhat different disease is observed in infants and small chil- 
dren. It begins similarly to an acute suppuration of the middle ear, but 
a fluctuating swelling of the mastoid process soon follows. It leads, if 
left alone, to fistulous perforations and progressive enlargement of the 
lymph glands of the neck attaining sometimes a considerable degree. 
The opening in the tympanic membrane in some cases remains small, in 
others a perforation does not even take place, or it is covered by granu- 
lations. We find in operating after the inflammation has lasted for 
some time, a cavity in the bone filled with flabby pale granulations sur- 
rounding several sequesters. 

The processes heal like those after empyema of otitis media puru- 
lenta acuta, if the general health of the children is good. A cavity in the 
bone behind the ear which may be left after the removal of a large se- 
quester, becomes lined by the advancing growth of epidermis as in a 
healthy organism. 

The necrosis progresses irresistibly in poorly nourished atrophic 
children of the first few years, who suffer from other general diseases. 
The bare bone only partially becomes covered with granulations, facial 
paralysis often sets in, and the children die from their general disease 
which is most frequently tubercular meningitis. 

Several authors assume that a tuberculosis of the bone of the mas- 



214 Tuberculous Fibrinoid of the Middle Ear. 

toid process originating from the blood, is often found in very young 
children. This assumption seems to be justified from the histologic find- 
ings, and in view of the fact that the disease in the bone is often spread 
beyond the pneumatic cells. 

Tubercular Fibrinoid of the Middle Ear. 

The formation of fibrinous exudations on the outside of the tym- 
panic membrane (otitis externa crouposa) is a comparatively frequent 
disease of the external ear. Fibrinous exudations in chronic suppura- 
tions of the middle ear through large perforations in the tympanic mem- 
brane are on the contrary rarely observed. 

I noticed such exudations several times on the wall of the promon- 
tory in otherwise characteristic cases of otitis media purulenta phthisica. 
Scheibe examined them microscopically and in 1897 published six cases 
which showed this unusual form of inflammatory reaction in chronic sup- 
puration of the middle ear. 1 

There were always large, usually total perforations of the tympanic 
membrane. Some of them showed epidermisation of the upper parts of 
the tympanic cavity, and obstinate odorless muco-purulent secretion. 
Suddenly, together with an increase of secretion, a tightly adherent thick 
layer of gray fibrin appeared on the wall of the promontory. It dis- 
appeared gradually after several weeks while at the same time healthy 
granulations formed. Particles of the fibrin and the fluid secretions con- 
tained tubercle bacilli in varying quantity during the whole time. The 
coagulated exudation is very similar in its microscopical and chemical 
condition to the fibrinoid which Schmauss and Albrecht 2 found in the 
lungs as an introductory state to cheesy degeneration of the tubercles. 
It does not show Weigert's reaction for fibrin. 

All of these patients showed other symptoms of slight, usually sta- 
tionary, tuberculosis. 

The suppuration in the ear never manifested a destructive character, 
and in all cases which remained under our observation healed by means 
of boric acid treatment after a number of weeks. The parts of the tym- 
panic cavity which were formerly covered with the coagulated exuda- 
tion, becarrie epidermized later on. 

A large number of cases have since been observed. In no case and 
in no specimen were Koch's bacilli in pure cultures absent in the fibrinoid. 
The fibrinoid contained at times such an abundance of them that one 
might have thought there was an artificial culture under the microscope 
(compare fig. 69). Some bacilli showed indications of formation of 
pearl strings. They proved characteristically pathogenous to animals. 
Inoculations in the anterior chamber of guinea pigs and rabbits caused 



1 Ueber leichte FSlle von Mittelohrtuberkulose und die Bildung von Fibrinoid bei denselben. 
Zeitsch. f. O. Vol. 30. 

2 Virchow Archiv. 144 suppl. 1896. 



Tuberculous Fibrinoid of the Middle Ear. 215 

the typical formation of a tubercle at the place of inoculation and a ring 
of tubercles in the vicinity. 

In spite however of the abundant formation of Koch's bacilli in the 
tympanic cavity none of the patients observed during the time of the 
formation of the fibrinoid showed any fever or loss of weight or strength, 
nor did the general condition grow worse. 

The great theoretical interest of this form of local tubercular dis- 
ease of the ear is no doubt evident to everybody. 

There is an irresistible decay of the tympanic membrane of the lin- 
ing of the middle ear and of its bony walls in the common form of 
otitis media phthisica, while the number of Koch's bacilli is in no propor- 
tion to the extent of the destruction; often they can not be found at all 




Fig. 69. 
Fibrinoid with a great many tubercle bacilli. 

in the secretions. On the other hand as long as the formation of the 
fibrinoid lasts we always find an abundance of Koch's bacilli, sometimes 
in incredible numbers in symbiosis with the human organism, which 
does not suffer from them in any way. They even seem to start some 
kind of a curative process by forming the fibrinoid. 

It must however be left to the bacteriologist to follow up the im- 
portance of these clinical observations in the ear for the position of 
Koch's bacilli and for the pathogenesis of phthisis in general. 

Other Forms of Caries and Necrosis of the Middle Ear. 

We have mentioned that otitis media purulenta acuta occurring in 
the course of some serious acute infectious disease like scarlet fever, 



216 Caries and Necrosis. 



measles, influenza, typhoid fever, etc., may lead to uncovering of ex- 
tensive parts of bone and later on to formation of sequesters. 

Caries and necrosis in the course of otitis media purulenta chronica, 
besides being found in consumptives, scrofulous and atrophic children, 
and in those suffering from rickets, are also found in tertiary syphilis, 
though only exceptionally very extensively developed. 

A few words must now be said about osteomyelitis in the temporal 
bone which however does not occur as frequently as some surgeons 
think. 

Osteomyelitis of the bones of the skull, especially of the temporal 
bone, and in connection with suppuration of the middle ear, is an ex- 
tremely rare disease according to a late compilation of R. Schilling. 1 It 
is peculiar that it most frequently attacks young women (which to me 
suggests lues congenita according to my experiences in deaf-mutes, al- 
though Schilling did not find any other support for this view). 

The purulent inflammation does not stop in the cells of the mastoid 
process where it begins, but progresses irresistibly along the large 
Breschefs veins in the bone to the squama, and beyond. The formation 
of corresponding subperiostal and extradural abscesses is absolutely 
characteristic for osteomyelitic disease of the bone. The surface of the 
bone is discolored and rough. Some few foci of suppuration in the 
diploe are found in the earliest stages. A large number of sequesters 
are later on isolated. The beginning of new formation of bone was 
found only in one case, which recovered. 

Three cases were examined bacteriologically ; staphylococcus was 
found in one, streptococcus in one and pneumococcus in one ; this in an 
infant of nine months with a rapid course of the disease, death occurring 
six days after the beginning of the acute suppuration of the middle ear. 

The course is usually a more protracted one. The dura in these 
cases also resists very long. Even this bulwark is finally overcome and 
death ensues. 

Osteomyelitis succeeding suppuration in the cells of the mastoid 
process is established when elevation of temperature, pain and oedema in 
the surroundings of the focus of the disease persist, and incessantly ex- 
pand even after the focus has been uncovered by operation. 

The whole course of osteomyelitis of the temporal bone is totally 
different from all our other observations in this locality. We are there- 
fore justified in suspecting that some serious general diathesis is the in- 
stigator of this process, if it is not lues as before mentioned. 

Besides the described diseases of bone there are some cases in which 
certainly no general disease preceded or accompanied the development 
of the necrosis of bone. We have to look for some local cause for the 
abnormal course in such instances. 



i) Ueber die Osteomyelitis der flachen SchMelknochen "Zeitschr. F. Ohrenhlk. Vol. 48. Er- 
ganzungsheft, page 52. 



Treatment of Ot. Med. Pnrul. Phthisica, Caries and Necrosis. 217 




I described one of these cases 27 years ago. 1 It may be mentioned 
as an example. 

An otherwise absolutely healthy woman suffered from congenital 
cleft palate and consequently of chronic processes in both middle ears. 
In order to improve her hearing she intro- 
duced Yearsley's cotton balls (compare later) 
into her tympanic cavity almost daily for 14 
years, so that the depth of the meatus of one 
ear was closed by polypoid growths. After 
their removal I extracted through the meatus 
the sequester portrayed in fig. 70. One end is 
the rear wall of the tympanic cavity, against 
which the cotton ball was pressed, the other 
end extends to the sigmoid sinus and repre- 
sents a part of its bony wall. The remaining 
cavity became epidermized later on. 

Cotton balls and other foreign bodies 
which remained in the tympanic cavity have 
probably often played a similar role in the 
development of caries and necrosis. 

Cholesteatomatous masses which have 
been allowed to gather and decompose for years consequently acting as 
foreign bodies, are found much more frequently than the foregoing to 
be the cause of more or less extended caries and necrosis of the surround- 
ing bony walls. 

Gross neglect for long periods of time and consequently far pro- 
gressed putrid decomposition is found in all such cases. The surround- 
ing soft tissues over quite an area are of a greenish color and partly de- 
cayed under the influence of the initial decomposition. Such processes 
are, according to my experience, absolutely excluded in an otherwise 
healthy organism under correct treatment, von Troeltsch long ago laid 
great stress on the importance of decomposition as a cause of destruc- 
tive processes. 



Fig. 70. 

Bony sequestrum. 

a sulcus sigmoideus, b posterior 

wall of the drum cavity. 

The lower view shows the inner 

surface of the antrum. 



Treatment of Otitis Media Purulenta Phthisica, Caries 
and Necrosis. 

The simple antiseptic treatment which was advised for suppurations 
with central perforations suffices as a treatment of otitis media purulenta 
of consumptives, as long as the suppuration keeps within moderate limits 
and there is no pain. 

The tuberculous fibrinoid of the middle ear which we discussed be- 
fore needs no other treatment than occasional use of the antrum tube. 

Severe persisting pain, profuse secretion, swelling and granulations 



1 Arch. f. Ohrenheilk. Vol. XIII, page 58. 



218 Treatment of Ot. Med. Purul. Phthisica, Caries and Necrosis. 

in the meatus in otitis media purulenta phthisica, indicate with great cer- 
tainty the presence of a large sequester, which ought to be removed, no 
matter how far the general disease has progressed. 

We were formerly more conservative as to operative interference in 
these cases on account of the general disease. 

Experience however has gradually shown that the operative inter- 
ference in extensive caries necrotica which causes considerable suppura- 
tion, swelling of the walls of the meatus, pain, etc., is of great benefit 
even to advanced consumptives. 

The radical operation is always necessary. It is not very difficult in 
these cases, the bone never being sclerosed, on the contrary very thin and 
often extraordinarily brittle. We can not always remove everything that 
is diseased if for no other reason than to avoid a fatal hemorrhage from 
the large blood vessels. Still we are often surprised at the favorable in- 
fluence which an extensive uncovering and cleaning of the focus has, not 
alone upon the local process, but also upon the general condition of the 
patient, the temperature, the increase in strength and weight. 

The local reaction after the operation amounts to nothing. The form- 
ation of granulations around the exposed necrotic bone always keeps with- 
in moderate limits, so much so that often the epidermis progressing from 
the outside grows close to the necrotic bone, because a ring of granula- 
tions is totally absent. The suppuration can be kept within moderate 
limits and odorless. Necrotic pieces of bone which become demarcated 
and movable in the late course of the disease can easily be removed 
through the big opening. 

Even though we are not able in far progressed cases of phthisis, to 
bring about a complete cure of the local process, still it remains painless, 
after the operation, and is not another factor to accelerate the unavoid- 
able result. 

Mastoiditis tuberculosa of children requires either Schwartze's or a 
radical operation according to the extension of the disease of the bone. 

The prognosis of tubercular mastoiditis in children is generally fa- 
vorable because tuberculosis in children is in most cases a merely local 
process. A complete cure however often requires considerable time. The 
prognosis is more unfavorable the younger the child, and the poorer its 
general nutrition. 

The careful supervision of the general condition of the patient in all 
these local processes is a duty which ought never be neglected. These few 
remarks must however suffice, as a more careful explanation of details 
is beyond the scope of these lectures. 

The bone in mastoid operations directly after acute infectious diseases 
is often bare to a large extent. This is however no proof that the bone 
is definitly dead. I saw for example in extensive operations right after an 
attack of scarlet fever, measles, typhoid fever, and even after a beginning 
tuberculosis, how all the cells were bare of their lining, the bone yellow, 



Treatment of Ot. Med. Pur id. Phthisica, Caries and Necrosis. 219 

and yet it recovered, became gradually red, and by and by covered with 
granulations, though sometimes only after 10 or more days. In similar 
cases it is therefore sufficient to give free drainage to the pus in the mid- 
dle ear, provided there are no cerebral complications present. Then we 
ought to wait and see, if and how much bone is going to be eliminated. 

No general rules can be made as to what ought to be done if a se- 
quester has formed or becomes more or less demarcated. 

Sometimes we are able to extract a large loose sequester through the 
meatus or through a fistula behind the ear by means of a forceps, after 
the granulations have been removed; in other cases however the total 
removal of dead bone in connection with radical operation may extend to 
the dura of the middle and posterior cerebral fossa, especially in caries 
and necrosis of the bony walls surrounding large decomposed masses of 
cholesteatoma. 



LECTURE XXIII. 

Labyrinthian and Endocranial Complications in Acute 
and Chronic Suppurations of the Middle Ear. 

A. Complications of the Labyrinth. Suppurations and Necrosis 

of the Labyrinth. 

Gentlemen: — The progress of an inflammatory process from the 
middle ear to the inner ear, that is, the development of a panotitis, 
whether in the course of an acute or chronic suppuration of the middle 
ear must always be considered a serious complication which is directly 
dangerous to life. 

104 out of 198 cases of suppuration of the labyrinth which Hinsberg' 1 
gathered from literature terminated fatally. 

Friedrich a short while ago published a very careful monograph 
about ''suppurations of the labyrinth of the ear 1 ' based upon the large 
material of the ear clinics of Halle and Kiel. He comes to the conclusion 
that there is about one case of suppuration of the labyrinth to every 100 
cases of suppuration of the middle ear. 

Suppurations of the middle ear occurring in the course of acute 
infectious diseases, particularly scarlet fever and measles, are especially 
prone to advance to the spaces of the labyrinth. Tuberculosis principally, 
but also diabetes and lues, are the chronic general diseases which are sim- 
ilarly responsible for this progress. 

Acute suppurations of the middle ear occurring in old age are 
equally apt to perforate into the labyrinth. 

It is however very rare that we observe this cause in an acute sup- 
puration of the middle ear in an otherwise healthy and strong organism. 

Among the local causes cholesteatoma, of all chronic suppurations, 
is oftenest complicated by invasion of pus into the labyrinth, on account of 
pressure atrophy and caries in its surroundings. 

A number of cases of panotitis must be attributed to injuries during 
operations, like unintentional removal of the stapes, opening with the 
chisel of the horizontal semicircular canal, etc. 

The usual avenues by which suppurations of the middle ear enter 



iZeitschr. f. Ohrenhlk. vol. 40, page 117. 

220 



Symptoms of Suppuration of the Labyrinth. 221 

into the labyrinth are the round or the oval windows, or both (the latter 
especially in consumptives). An acute empyema of the mastoid process 
may furthermore reach the labyrinth through cells surrounding the laby- 
rinth from the inside, which are sometimes especially well developed. It 
may enter through the rear semicircular canal under these circumstances. 
In chronic suppurations these cells, except in consumptives, are filled with 
sclerosed bone long before such an occurrence is possible. 

The characteristic symptoms of irritation of the labyrinth were pres- 
ent, at least in the beginning, in all cases that I observed of perforation 
of a suppuration of the middle ear into the labyrinth. These symptoms 
are a subjective feeling of dizziness, dizziness in rotation and lying down; 
objectively, irregularities in walking, horizontal nystagmus in looking 
towards the healthy side, and vomiting. The nystagmus is sometimes 
rotating and disappears sooner than dizziness. 

The result of hearing tests furnishes reliable conclusions as to sup- 
puration of the labyrinth, only under the condition that the power of 
hearing has entirely disappeared in the affected ear ; that is if it shows a 
weak reflected image of the hearing of the other, the good ear. We 
shall learn in speaking about necrosis of the labyrinth how characteristic 
this reflected image is. 

Subjective noise and violent headache are always present in the 
beginning, even though they are often overshadowed by other serious 
symptoms. There is no pronounced elevation of temperature as long as 
the suppuration remains confined to the labyrinth. 

You will understand how easily a suppuration after having reached 
the spaces of the labyrinth, will spread there and how rapidly it will 
extend to the meninges if you consider the following facts : all spaces of 
the labyrinth communicate freely with each other and have open avenues 
(compare page 14) through the porus acusticus internus, and the aquae- 
ductus cochleae, directly into the subarachnoidal space, and through the 
aquaeductus vestibuli into the saccus endolymphaticus, which lies between 
two leaves of the dura. Suppurations of the middle ear of consumptives 
form an exception, as they rarely lead to cerebral complications although 
they invade the labyrinth comparatively frequently. 

It is probable that in a number of cases a wall of granulations is 
formed which checks the further spreading of the inflammation. This 
wall may form in the surroundings of the place of perforation, around the 
windows, etc., or in the porus acusticus internus and in the aquaeducts 
if panotitis has already developed, or later on when necrosis of the laby- 
rinth has begun in its whole surroundings. 

A large number of pathological findings in the ears of deaf-mutes 
who had only partially lost their hearing after a suppuration of the middle 
ear had progressed to the labyrinth, allows us to accept the first men- 
tioned possibility. 

In such cases we observe for example that the hearing of a large part at 



222 Treatment of Suppuration of the Labyrinth. 

the upper end of the sound scale is lost. According to Hclmholtz s theory 
this justifies the conclusion that the suppuration invaded the basal coil of 
the cochlea through the round or oval window. The destruction was 
confined to this coil or only a part of it. I draw your attention to fig. 27 
which shows the diagram of hearing of a number of deaf mutes. 

On the other hand we are comparatively often in a position to ob- 
serve clinically the gradual expulsion of sequesters which form parts 
of the bony labyrinth. They could only develop after a well defined 
panotitis had cut off the nutrition of the bone which in turn caused such 
intense reaction all around, that every entrance to the interior of the 
skull was closed by a wall of granulations around the forming sequester, 
thus protecting the interior of the skull from the invasion. 

The statistics of Hinsberg, previously mentioned, show r however 
how numerous the cases are which succumb, because this protection does 
not take effect and the skull cavity remains freely accessible. 

Death occurs here most frequently from leptomeningitis, and in a 
comparatively large number from abscesses of the cerebellum. 

In 60 cases out of 104 compiled by Hinsberg the cause of death was 
meningitis alone, in 6 it was meningitis combined with abscesses of the 
cerebellum, 13 times abscess of the cerebellum alone, and in the other 25 
cases the fatal result was brought about by "other diseases." 

Empyema of the saccus endolymphaticus usually forms the connec- 
tion in the development of abscesses of the cerebellum. We find a bag of 
pus on the rear surface of the pyramid corresponding to the slit of the 
aquaeductus vestibuli, or sometimes also corresponding to the posterior 
vertical semicircular canal, which is destroyed by caries. This bag has 
become broadly adherent to the surface of the cerebellum and formed 
the avenue for the suppuration from the labyrinth to the cerebellum. 
Diffuse leptomeningitis is the direct consequence if the thin leaves of the 
bag of the dura burst. 

The question of therapy in cases of fresh invasion of the labyrinth is 
an extremely difficult one. 

There can be no doubt but that theoretically an extensive operation, 
uncovering all the cavities in the bone containing pus might create the 
most favorable conditions. Accordingly a very complete opening of all 
spaces of the labyrinth in connection with radical operation was re- 
peatedly tried. Many a "latent" suppuration however became "florid" 
after this procedure, in other words meningitis followed directly after the 
operation. Recent authors are therefore very reserved as to entering the 
labyrinth by operation. Friedrich classes them among "the most serious 
operations, which we are not justified in undertaking without vital indi- 
cations," and reminds us of how easily adhesions may be separated which 
formed the only protection against the danger of invasion. 

The heavy shock from chiseling the sclerosed bone during a radical 
operation must be considered dangerous in recent suppuration of the 



Treatment of Suppuration of the Labyrinth. 223 

labyrinth. In the findings of a post-mortem which I made a short time 
after one of these operations, there was a large number of separate 
leptomeningitic islands with fibrinous purulent exudation all around 
the porus acusticus internus. The impression admits of no doubt in my 
mind that in this recent case these islands corresponded to small particles 
of pus which were scattered by the shocks of chiseling from the porus 
acusticus internus over a large surface of the subdural or arachnoideal 
space. 

Since then I have made it a rule, at least in chronic suppurations of 
the middle ear with sclerosis of the bone and symptoms of a recent 
invasion of the labyrinth to postpone radical operation unless vital indica- 
tions are present. The most important of these symptoms is sudden ap- 
pearance of complete deafness. 

Later on when the demarcation and the formation of a sequester 
of the wall of the labyrinth has taken place there is no reason for hesita- 
tion in laying bare the spaces of the middle ear, according to my own 
experience and to that of others.. 

It is of greatest importance to watch carefully for the first symptoms 
which may point to a threatened invasion of the labyrinth. 

I observed them especially clearly in the course of acute suppura- 
tions of the middle ear. These symptoms are sudden appearance of diz- 
ziness and disturbances of the equilibrium, sudden loss of the power of 
hearing and especiall) rapidly progressing loss of hearing at the upper 
limit of the sound scale, which is tested by means of the Galton whistle. 
They are an urgent indication for immediate operative opening of the 
antrum and the cells, and in chronic suppurations with cholesteatoma or 
caries, for radical operation. It is preferable not to disturb the wall of 
the labyrinth, even if there is an old suppuration of the labyrinth, except 
when unmistakable signs, like a granulating fistula are found in the wall 
of the labyrinth, or an enlarged oval window filled with granulations. 
The fistula ought to be carefully enlarged with a very small chisel with- 
out scraping the granulations in the depth. 

The necrotic expulsion of some parts of the labyrinth has been clin- 
ically observed in a large number of cases, also, though rarely, of the 
whole labyrinth, and even of sequesters representing still larger parts of 
the temporal bone. 

As early as 1886 I gathered 46 cases from literature 1 5 of them I 
reported myself. Gerber 2 in 1903 brought the number up to 90. 

To the present time I have observed 13 cases. According to my 
statistics there is one case of necrosis of the labyrinth to every 3,000 gen- 
eral ear patients, and to every 500 cases of chronic suppurations of the 
middle ear. 

Only one of those 13 cases terminated fatally, and even this one 



1 Labyrinthnekrose and Facialisparalyse Z. f . 0. Vol. 16. 
•A. f.0. vol. 60, page 16. 



224 



Necrosis of the Labyrinth. 



after the sequester was expelled. The patient suffered at the same time 
from necrosis of the maxilla 1 . I obtained furthermore the temporal bone 
of another fatal case for examination. Here the sequester, representing 
the cochlea, was still imbedded. 

This shows that the prognosis is not so unfavorable if a demarcating 
formation of granulations has taken place all around the sequester. 

The clinical picture of gradual elimination is so characteristic that in 
my last cases I could predict far in advance the appearance of a seques- 
ter of the labyrinth. 

This picture offers a number of interesting points. 

They were mostly patients with long neglected or unsuitably treated 
chronic suppurations of the middle ear. They came to us only after they 
had suffered from pain and continual insomnia for many months. Their 
general condition was therefore badly run down although there were no 
other general symptoms. 





Fig. 71. 

Sequestrum consisting of the whole basal coil of the cochlea. 
a as seen from the outside, b as seen from the inside. 



The beginning of the necrosis of the labyrinth could usually be de- 
termined in the anamnesis from the time when the dizziness was worst. 
Dizziness becomes less prominent later on. 

Paralysis of the facial nerve is only exceptionally absent in the later 
course. It begins with a paresis which follows several months after the 
first attack of dizziness, and may be taken as the first sign of the fact 
that the sequester has become movable. The picture in the depth of the 
meatus becomes at the same time very characteristic. The thin fetid dis- 
charge which was there from the beginning becomes even more profuse. 
New granulations with a broad base on the promontory spring up very 
quickly as soon as they have been removed, which has to be done 2 to 3 
times a week by means of the snare, in order to create free drainage for 
the pus. The granulation, when it is well caught at its base, is always 
very painful, because the sequester lying underneath is touched. The 
granulation is perforated in the center, which is a proof that it was on 
the opening of a fistula in the promontory. The pain, the suppuration 
and the formation of granulations decrease gradually later on. After sev- 
eral more months of scant secretion have passed, the bare bony sequester 



*Z.f. O. vol. 30, page l: 
in the history. 



Case Seemfiller. The necrosis of the maxilla is not mentioned there 



Necrosis of the Labyrinth. 225 



appears in the depth. of the meatus and can easily be removed in the 
majority of cases. 

In three cases I performed a radical operation on account of the 
especially profuse discharge and luxuriant formation of granulations. 
The sequester appeared however even in these cases only later on, as I 
do not think it is permissible to seek it forcibly for reasons which I ex- 
plained before. 

The sequester forms a part of the basal coil of the cochlea in 
the majority of cases (compare fig. 71 ) . This fact indicates that the round 
or oval window formed the avenue of invasion through which the sup- 
puration passed into the labyrinth. In one case an especially large se- 
quester had been expelled through an opening which had formed spon- 
taneously for that purpose behind the ear many years before I saw the 




Fig. 72. 

Sequestrum consisting of the whole petrous portion of the temporal bone, the 
labyrinth, the porus acusticus internus, the promontory, and a large part of the 
Fallopian canal. 

a as seen from the outside, b as seen from the inside. 

case for the first time. The sequester reached from the porus acusticus 
to the wall of the promontory which was eliminated with it (compare 
fig. 72). 

Cases of necrosis of the labyrinth are also of great physiological 
interest, as they alone put us in a position to ascertain the finding of the 
function in one-sided deafness, the presence of which can of course not 
be doubted in these cases. 

A number of authors thought they could show remnants of hearing 
after parts of the labyrinth were expelled. Lucae-Dennert's test however 
proved long ago that mistakes were made somewhere. This is no more 
than could be expected. This test consists in hearing tests for whisper 
made by alternately opening and closing the diseased ear while the other, 
the healthy ear, is kept tightly shut with a moist finger. The patient 
hears whisper or conversation just as well with the diseased ear closed 
15 



226 



Hearing in Necrosis of the Labyrinth. 



as open. This remnant of hearing can not be attributed to the diseased 
ear but proves that we are not able to exclude hearing with the good ear, 
as is shown also by the considerable remnants of hearing in patients with 
congenital atresia of both external canals (compare page 101). 

This test can be made more accurately by means of the continuous 
series of sounds. We test as in deaf-mutes the duration of hearing by 
air conduction for octaves and fifths throughout the whole extent of 
hearing. 

The lowest part of the scale up to the octave from a to a' is not 
heard on the side of the head where there is no labyrinth. Hearing 
increases more and more the higher we ascend in pitch from this octave 
(compare fig. 73) . The picture of the diagram of hearing of the ear with- 
out a labyrinth, which we obtain in 
this way, is nothing else than a 
faint image of the hearing of the 
other, the healthy ear. This is 
proved most accurately in those 
cases which show irregularities of 
hearing in the better ear. We find 
gaps of hearing in the ear without 
a labyrinth which absolutely cor- 
respond to the irregularities in the 
better ear. Four cases of necrosis 
of both labyrinths showed lately 
that the ear without a labyrinth is 
absolutely deaf. 

This diagram of hearing which 
we observe in each case of one- 
sided deafness is of utmost impor- 
tance for diagnosis and treatment 
for you know, gentlemen, that our 
whole therapeutical action in a be- 
ginning invasion of the labyrinth depends principally upon the question 
whether or not the labyrinth is still free from pus. 

The paralysis of the facial nerve disappears in most cases, especially 
of small sequesters of the cochlea, during the migration of the sequester 
or soon after. It usually remains permanent after the expulsion of large 
sequesters, enclosing also the vestibulum. The function of the nerve, or 
at least of some of its parts, may return even after years. What an incred- 
ible amount of regenerative power must be attributed to this nerve is 
shown by the case to which the sequester reproduced in fig. J2 belongs. 
You see from this picture that the sequester includes the largest part of 
the canalis Fallopii. The facial nerve must have been severed in the 
gradual expulsion of the sequester which occurred in early childhood. 
When I saw the patient as a young woman there was still the gap in the 




Fig. 73. 

Diagram of the apparent power of 
hearing of the ear that has no laby- 
rinth, while the other ear hears nor- 
mally. 



Endocranial Complications. 227 

bone behind the ear through which the sequester had passed. It was 
filled with granulations, but there was no trace of the paralysis of the 
facial nerve. The patient herself was not aware that she ever had a 
paralysis yet we can not doubt its having been present. 

The suppuration stopped in all cases after the sequester was ex- 
pelled and the last granulation was removed. The patients must however 
be controlled from time to time during later years because cholesteatoma 
may gather in the cavity which becomes lined with epidermis. 

B. Endocranial Complications of Acute and Chronic Sup- 
purations of the Middle Ear. 

The progress of acute and chronic suppurations of the middle ear to 
the meninges, the large blood vessels and the brain, may cause a large 
number of complications. 

Extradural Gatherings of Pus. 

They are the mildest and most frequent concomitant of suppurations 
of the middle ear, and are almost always the intermediary in the devel- 
opment of other more severe complications. (The empyema of the 
saccus endolymphaticus which we discussed before is usually an extra- 
dural gathering, as according to my experience the external leaf of the 
sack is very thin and perforates early, evacuating the pus between the 
bone and the dura). There are therefore only two complications which 
do not depend upon a gathering of the pus between the dura and the bone 
as their intermediary for endocranial complications, namely, the suppura- 
tive processes which extend through the aquaeductus cochleae and those 
through the porus acusticus internus. The subarachnoidal space and the 
space of the labyrinth are one and the same space, and do not need an 
intermediary for the extension of a suppuration. 

We shall first discuss the pathogenesis of the extradural gathering of 
pus which is so important practically. 

The first question is, which are the avenues for the pus to reach the 
dura from the spaces of the middle ear. Let us recall the anatomical 
structure of the complicated system of cells. The size of the cells varies 
greatly. The largest terminal cells at different places are in closest prox- 
imity to the dura. We learned that the larger the cells are, the more 
difficult is the absorption of an empyema which develops in them. There 
is furthermore a rarefying osteitis with the formation of osteoclasts in 
the walls, leading to a progressive excentrical enlargement of the spaces, 
till the pus finds some place where it perforates through the bony wall, 
either outwardly or inwardly. Large pneumatic cells are found 
especially frequently throughout the whole extent of the sulcus sigmoi- 
deus, in the hight of the antrum, and lower, in its horizontal part which 
is closer to the bulbus, as well as around the bulbus itself. The wall of 



228 Extradural Abscess. 



the sulcus is often so thin that it is translucent. A large number of small 
blood vessels, which can clearly be demonstrated in the corrosion speci- 
men, pass from the lining of the cells to the wall of the sinus. 

All these conditions come into consideration only in acute suppura- 
tions of the middle ear in a highly pneumatic temporal bone. Everything 
is changed after the suppuration has lasted for some years. The cells are 
partly or entirely filled with bone and nothing but the aditus and the antrum 
remain. This explains the fact that extradural gatherings of pus in the 
sulcus sigmoideus are mainly found as complications in the course of 
otitis media purulenta acuta. We sometimes, in opening the cells after a 
few weeks' duration of an acute suppuration, find the outer wall of the 
mastoid process rather thick, while the inner wall of the cells is absorbed 
to the extent of 2 centimeters and more where the wall of the sinus 
throughout its entire length forms the inner limit of the empyema. The 
extradural gathering in other cases develops much later, sometimes sev- 
eral months after the perforation in the tympanic membrane has closed. 
There are cases which from the beginning never had a perforation. 

A suppuration extends to the middle fossa of the skull less frequently 
than to the rear fossa. This takes place from the cupola of the tympanic 
cavity, from the aditus ad antrum, or from the antrum itself through de- 
hiscences which are often found in the tegmen tympani et antri. It is 
favored by a sutura petroso-squamosa embracing a continuation of the 
dura. 

The pus which gathers between the bone and the dura has no odor 
if the pus in the spaces of the middle ear in acute suppurations remained 
odorless. This can easily be accomplished by keeping away all harmful 
influences from the outside. Caries and necrosis play a role in the prop- 
agation of the pus to the dura in acute suppurations only if they occur 
in an organism which is weakened by some acute general infectious dis- 
ease, or in diabetes, in old age, etc. 

An extradural gathering of pus after an acute otitis media purulenta 
extends only exceptionally over a large surface between the dura and 
the bone, thus forming a real extradural abscess. 

A spontaneous recovery is possible under favorable circumstances: 
the surface of the dura becomes covered with granulations which also 
develop all around the periphery of the focus. The pus may be evacu- 
ated backward through the middle ear and thence through the perfora- 
tion in the tympanic membrane or to the outside through a fistula in the 
soft tissues, or it may find an avenue along an emissary vein through 
the bone underneath the external soft tissues which it perforates later 
on. 

Extradural gatherings of pus occurring in chronic otitis media puru- 
lenta are different in many regards. 

The simple form of chronic suppuration with central perforation of 
the membrane hardly ever leads to a propagation of the suppuration, 



Extradural Gatherings of Pus. 229 

according to my experience, provided it occurs in an otherwise healthy 
organism where the bone in the surroundings of the antrum is sclerosed. 

Extradural gatherings of pus are found more frequently in chronic 
suppurations with marginal perforations and gathering of masses of 
cholesteatoma, although not as often as in acute suppurations. They are 
also found in caries and necrosis of the walls of the middle ear whether 
they are due to merely local causes or to the influence of some serious 
generai diathesis. 

Cholesteatoma may lead to excentric enlargement of the cavity which 
surrounds it and to perforation of the inner wall of the skull the same 
as an acute empyema of the mastoid process. This is however a great 
exception. It has, as a rule, enlarged its communication with the external 
meatus by pressure, etc., or has perforated to the outer surface of the 
mastoid process long before it reaches the inner surface of the skull, pro- 
vided it can develop without being interfered with. 

A number of complications may however occur which put an end to 
their further development, and also to life, long before the cholesteat- 
omatous masses can even partially be evacuated in this way. 

We found no excessively large masses of cholesteatoma and no 
enlarged antrum in the vast majority of cases necessitating the uncover- 
ing by operation of an extradural focus of suppuration in connection 
with cholesteatoma. A small mass of decomposed epidermis, not larger 
than a pea, confined to the aditus ad antrum has often led not alone to 
an extradural abscess, but to a number of other complications which 
threatened directly the life of the patient. 

In the surroundings of the cholesteatoma and of the extradural ab- 
scess, there are always clear evidences of decomposition, such as 
pronounced fetor, partial discoloration of the tissues, and putrid decay 
of the soft parts, besides the suppuration, and the formation of granula- 
tions. These processes defy the protection afforded by a comparatively 
thick inner wall of the cholesteatoma cavity. Its nutrition in part is cut 
off and it becomes necrotic. 

There are two places in which this occurs especially frequently. 
The first is the rear end of the antrum, where only a comparatively thin 
wall separates the sinus from the antrum (compare fig. 16 page 33), 
the other is the thin tegmen tympani and antri. 

The middle and the rear cerebral fossae seem to become affected 
almost equally often, which is contrary to what we see in acute suppu- 
rations of the middle ear. 

The extradural gathering of pus, according to my experience, is 
in these cases always fetid, likewise the pus in the middle ear. The sur- 
roundings of the focus, the dura and the sinus, are usually discolored. 
The power of reaction of the tissues is lessened on account of the pro- 
cesses of decomposition. This must probably be accepted as the cause 
for the fact that the extradural suppuration leads here much oftener to 



230 Extradural Gatherings of Pus. 

gatherings of surprising extent, and to the formation of real extradural 
abscesses. 

The dura in chronic suppurations resists the progress of the process 
and the perforation inward apparently even for a longer time than in 
acute suppurations ; a similar occurrence to that which we may observe 
in caries of the vertebrae. 

The pus may reach the outer surface of the dura, if caries and 
necrosis are present. The prototype of this condition is otitis media pur- 
ulenta phthisica. The bone somewhere on the inner surface of the skull 
decays with or without the influence of saprophytes. The pus reaches the 
dura comparatively easily and frequently in consumptives, as sclerosis of 
the bone is totally absent ; the pneumatic cells are usually in abundance 
and are even excentrically enlarged by caries of their walls, while at 
the same time sequesters of different sizes are formed. The power 
of resistance of the dura against the process of suppuration is even 
greater in consumptives than in acute and chronic suppurations of the 
middle ear. Complications like abscess of the brain, thrombophlebitis 
and diffuse purulent leptomeningitis are very rare in otitis media puru- 
lenta phthisica in spite of the great length of time over which these pro- 
cesses extend in some cases. 

Clinical symptoms may be entirely absent in extradural gatherings 
of pus after acute or chronic suppurations of the middle ear. The most 
frequent symptom is one sided headache, lancinating towards the vertex. 
The existence of an extradural gathering of pus during a later state is 
sometimes betrayed by a secondary perforation of the pus into the ear, 
or by a perforation through an emissary vein underneath the external 
soft parts. 

By far the largest number of extradural gatherings in acute as well 
as in chronic suppurations are discovered at the time of the operation. 
Their frequent occurrence, which was thus recognized in the living, 
entirely justifies the indication for operation which was given some time 
previous. We have to uncover the spaces of the middle ear by operation 
and find the focus if acute suppurations of the middle ear do not cease 
after careful treatment for eight weeks, and if in chronic suppurations 
the fetor does not cease after a treatment of several months. 

You will now readily understand that the extradural gathering of 
pus is the process which forms the most frequent connecting link between 
suppurative otitis and the three complications, sinus phlebitis, abscess of 
the brain, and leptomeningitis, which we shall discuss in the next lectures 
and which usually end fatally. 



LECTURE XXIV. 
Sinus Phlebitis. 

Gentlemen: — The proximity of the external wall of the descending 
part of the sinus transversus, which is usually called the sigmoid sinus, 
to the rear end of the antrum and to the cells of the mastoid process, 
furnishes the explanation why the external wall of the sinus is frequently 
affected in chronic suppuration of the middle ear with caries of the bony 
wall. This may however also occur after a very short attack of an 
acute suppuration of the middle ear. An extradural gathering of pus 
around the walls of the sinus is not even necessary. 

Let me give you the findings at the post-mortem of a fresh acute sup- 
puration of the middle ear as an example. The suppuration was caused 
by a foreign body in the tympanic cavity wedged into the ostium of the 
tube (seed of a locust bean) and by fruitless attempts at extraction. The 
disease terminated fatally from meningitis after 3^ weeks. 1 

It is only the finding of the sinus which interests us here. 

"In the right sigmoid sinus there is an apparently fresh yellowish 
transparent goosegrease clot. It is adherent to the external wall, filling 
the otherwise empty aperture only partly. The clot can be easily lifted 
from the wall at both extremities above and below. It is however adher- 
ent at its center which is at the curve from the horizontal to the vertical 
part of the sinus. A drop of fresh pus can be squeezed from the clot by 
means of a probe pressing at the place of adhesion. The wall of the 
sinus is normal except at the spot where the clot adhered. After its 
removal a swelling the size of a lentil is seen, having a crater-shaped 
ulcer in its center with steep margins. After the removal of the sinus 
from its bony sulcus the wall of the sinus at this place is connected with 
the bone by a yellow infiltrated cord." 

I quote verbally this finding published in 1888 because I can hardly 
offer you a better picture of the pathogenesis of sinusphlebitis produced 
through the intermediary of little veins which pierce the bone (osteophle- 



I'Tremdkorper im Ohr." Berl. kl. Wochenschr. 1888 No. 26. (The case was observed at a time 
when the radical operation was not known as a safe method for removing similar foreign bodies from 
the ear.) 

231 



232 Thrombosis of the Sinus. 



bids. Koemer). There was no gathering of pus of any consequence be- 
tween the wall of the sinus and the bone. 

Supposing the fresh blood clot, which adhered to the wall and shut 
off the pus that formed on the inner wall of the sinus, had been detached 
from the wall by the current of blood and no new thrombus had formed 
in its place, free pus and pyogenous germs would have entered directly 
into circulation, and that form of pyemia would have developed which 
Koemer described as characteristic for osteophlebitis. The germs after 
passing the lungs would have entered the circulation and caused metas- 
tases in the peripheral parts, in the joints, in the muscles, in the subcuta- 
neous connective tissue, etc. This form developes only in acute suppura- 
tions of the middle ear according to Koemer. 

A solid thrombus adherent to the wall would probably have formed 
around the small focus of suppuration in the sinus, if the development 
had lasted longer during the life of the patient. One end of this throm- 
bus would have grown towards the heart, the other, the peripheral end, 
towards the horizontal part of the sinus, becoming an obstructing throm- 
bus. Daily experience shows that this thrombus very soon reaches the 
bulbus of the jugular vein, where the conditions for its formation are 
especially favorable, probably on account of the slackening of the current 
of blood. The thrombus thence progresses down the jugular vein where it 
may be torn loose and carried to the lungs. There it is retained on 
account of its size and causes metastatic infarctions or metastatic foci of 
suppuration if it is already decaying and purulent. 

We find the wall of the sinus to be yellowish transparent when we 
uncover it, after the thrombus in otitis media purulenta acuta has lasted 
for some time. In other cases there are either minute or large perfora- 
tions, and the aperture is filled to a certain distance with fluid pus which 
is in direct connection with the gathering outside the walls. The pus in 
the sinus is shut off at both extremeties, towards the brain and towards 
the heart, by a solid thrombus. The outer surface of the wall of the sinus 
is covered with luxuriant granulations to a large extent. They may 
reach upward as far as the transverse part, and downward as far as the 
bulbus. 

These foci of suppuration are usually odorless if foreign harmful 
influences were not allowed to take effect (poultices, tamponade of the 
meatus, etc.). 

However processes of decomposition originating from decomposing 
masses of cholesteatoma play an important part in the development of 
the thrombosis of the sinus in otitis media purulenta chronica. They 
usually lead to circumscribed caries and necrosis of the bony wall. The 
gathering of generally decomposed pus is of larger extent. The wall of 
the sinus is discolored greenish or blackish. The granulations on the wall 
of the sinus also are usually discolored. A dirty looking thick layer of 
fibrin sometimes takes their place. Later on a large area of the external 



Thrombosis of the Sinus. 233 

wall decays. Even the whole circumference of the sinus and a part of the 
adjoining dura may decay by necrosis and become loosened so that the 
pus is found in the subdural space (a very instructive case of this kind is 
described in Koemer's "Otitische Hirnerkrank," III edition, page 37). 

The pus is always very fetid, decomposed, and sometimes contains 
gas bubbles. Black, crumbly massses of thrombus and decomposed pus are 
found in the sinus. The inner wall of the sinus is usually found to be 
smooth but discolored after it has been opened, and the pus and the 
masses of thrombus have been removed. 

Thrombophlebitis in otitis media purulenta chonica usually leads to 
purulent metastases in the lungs as the emboli which become detached 
are generally large. 

The thrombosis of the sinus may spread enormously if the patient 
does not die at an earlier stage. 

It may creep backward through both sinus petrosi and affect not 
alone one but both sinus caver no si. The consequences are the well known 
symptoms of thrombosis of these sinuses namely oedema of the eyelids, 
chemosis, choked disk, retrobular abscesses, etc. The torcular Herophili 
and the transverse sinus of the other side may be reached from the hori- 
zontal part of the transverse sinus. Thence all other sinuses and the 
bulbus and internal jugular vein of the opposite may be reached. 

The bulbus of the diseased side succumbs to thrombosis very soon in 
chronic suppuration of the middle ear and the thrombosis sometimes pro- 
gresses very rapidly along the jugular vein down to the vena anonyma. 

Through special pathology you have become sufficiently well ac- 
quainted with the symptoms of thrombophlebitis with the consecutive 
septicopyemia and its metasases to make it unnecessary for me to discuss 
them in detail here. Chills are rarely absent. Enlarged spleen is found 
later on. The fever is pathognomonic for pyemia. It is irregular, remit- 
tent and intermittent and may vary from six to eight degrees a day. 

On the other hand there are some very exceptional cases where we 
find a purulent decomposed thrombus at a post-mortem, while during life 
no increase in temperature, or chills were recorded. 

In other cases there is a high continual fever partially due to general 
acute sepsis partially to leptomeningitis which started simultaneously from 
the original focus of the disease. 

Consciousness may be retained to the very end in pure septicopyemia 
if other complications like abscess of the brain or meningitis did not 
develop simultaneously with phlebo-thrombosis. In childhood the lat- 
ter very often produces a number of cerebral symptoms even where it 
remains isolated. 

The prognosis of thrombophlebitis and septicopyemia in connection 
with chronic suppuration of the middle ear is nearly absolutely fatal, if 
the process is not interfered with. In acute suppurations of the middle 
ear this complication has a somewhat better prognosis, inasmuch as a few 



234 Thrombophlebitis of the Sinus. 

exceptional cases have even healed without an operative interference, 
simply by obliteration of the sinus. These few exceptions must of course 
not mislead us and keep us from uncovering the focus of the disease by 
operation as early as possible. 

An attempt at operation must be made even in cases which come 
under observation very late and where besides the sinusphlebitis other 
complications, like circumscribed leptomeningitis or abscess of the brain, 
are present, and where metastases in different parts of the body are 
found. The reason for this advice is the fact that the abscess of the brain 
is also accessible to operation and that circumscribed meningitis and metas- 
tases may heal. I saw for example in connection with cholesteatoma and 
thrombophlebitis a gangrenous metastatic abscess of the lungs heal after 
the sinus was cleaned out, although the abscess had involved an entire 
lobe. 

The prognosis of those cases which show an extension of the septic 
thrombosis to the other side seems to be absolutely unfavorable. At the 
operation of such cases severe venous hemorrhages from emissary veins 
were often a striking feature. In one case I could draw the conclusion of 
thrombosis of the sinus transversus of both sides from the transgression 
of the oedema of the external soft parts over the rear median line of 
the skull, to the other side. Conclusions as to thrombosis of both sinus 
cavernosi may be drawn in a similar manner from oedema of the lids of 
both eyes. I also repeatedly observed well pronounced choked disk in 
such cases. 

The condition of the temperature decides our therapy in thrombo- 
phlebitis. 

We are justified in immediately thinking of implication of the sinus, 
if the temperature rises in the later course of an acute suppuration of the 
middle ear, or if fever occurs in the course of a chronic suppuration of 
the middle ear (Leutert). Every rise of temperature which is not com- 
pletely explained by some other disease in the organism than the ear, is 
to us an urgent indication to uncover the focus of suppuration in the 
ear and the nearest threatened parts of the wall of the sinus. 

The mortality from suppurations of the middle ear will in the future 
no doubt decrease considerably if such cases are referred in time to the 
otologist by general practitioners. 

A complete uncovering of the otitic focus of suppuration and of an 
extradural gathering, if such is present, is entirely sufficient during the 
first few days of such a rise in temperature in acute suppuration of the 
middle ear and also in some chronic suppurations. 

We have however to expect an extensive thrombus in the sinus if 
the general disease has lasted for many days. Any brisk movement of the 
patient during this time, a firm pressure on the neck in examining the 
region of the jugular vein, the shaking during transportation, etc., may 
cause the detachment of an embolus and consequent metastasis. 



Thrombophlebitis of the Sinus. 235 

The ear surgeon after uncovering the otitic focus in such cases has 
often to follow up the sinus to the bulbus of the jugular vein, slit it open 
and clean it out. There is furthermore a great question which he has to 
answer : should he ligate the vena jugularis interna either before or after 
opening the sinus. 

Koerner compiled 314 cases of operated sinusphlebitis in the III 
edition of his previously mentioned book (page 118) ; 180 of them or 58.4 
per cent, in other words more than half, had their lives saved. This figure 
shows how much the prognosis of this disease has improved since the 
operative treatment was introduced. 

Koerner gives the following information as to the different methods 
of operation which were used in the 314 cases of otitic sinusphlebitis and 
about the results of each method. 

The sinus was opened without ligating the jugular vein in 132 cases 
of which JJ, or 58.3 per cent were cured. The jugular vein was ligated 
before opening the sinus in 94 cases, 56 of them or 59.6 per cent were 
cured. The jugular vein was ligated after opening the sinus in 69 cases, 
38 of them or 55.9 per cent w r ere cured. 

None of these three methods has an evident advantage according to 
the percentage of recoveries and Koerner justly draws the conclusion 
"that it is best to adapt the method and extent of the operation to the 
finding in each case. To ligate the jugular vein in all early and late op- 
erations for throm phlebitis of the sinus as a matter of principle seems 
under all circumstances not justified according to the number of recov- 
eries without litigation." 

A statistical compilation of 200 operated cases of sinus thrombosis 
which Toubcrt published a short while ago 1 is especially valuable. It 
shows with sufficient accuracy that the favorable results do not depend so 
much upon a certain method of operation as upon an early interference. 
120 of the 200 cases were operated within the first week after the appear- 
ance of endocranial symptoms. There were 25 per cent of deaths and 75 
per cent of recoveries. The other 80 cases could be. operated upon only 
after the first week; of these 62.5 per cent died and only 37.5 per cent 
recovered. 

These figures show clearly that the destiny of the patients is rather 
in the hands of the general practitioner, and depends much more upon 
his accurate and timely recognition of the dangers which threaten the 
patient than upon the method of operation which the surgeon may apply 
in a given case. 

There can be no doubt as to the necessity of ligating and cutting the 
jugular vein whenever the purulent decomposition in the sinus extends 
below the bulbus into the jugular vein. The advice of Alexander in such 
cases seems suitable, which is to suture the upper open end of the vein into 
the skin in order to create free drainage through the vein. 



1 Arch. Internat. d'otol. etc., Vol. 18, page 437. 



236 Acute Sepsis. 



The sinus is uncovered, starting from above down to the bulb, after 
the whole mastoid process has been removed. The external wall of the 
sinus is excised. An injury to the facial nerve in chiseling can be avoided 
by a man who is well versed in the anatomical conditions. 

The bulbus may be carefully dried out by means of probes wrapped 
with cotton and bent into different curves after we have opened the sinus 
close enough to the bulbus. I do not think that the insertion of gauze 
packings in the upper or lower part of the opened sinus or bulbus is 
necessary or even advisable. By direct inflation of boric acid powder into 
the upper as well as in the lower part I often saw processes of decomposi- 
tion inside the vein disappear within a few days. The aperture of the 
sinus and bulbus remains wide open under the dressings for weeks dur- 
ing the after-treatment. It fills with granulations later on after the pro- 
cess of suppuration has run its course. 

In proceeding as described during the operation and after-treatment 
I never saw the necessity for splitting the soft parts beyond the bulbus, 
thus converting the sinus, the bulbus, and the jugular vein into one unin- 
terrupted groove, as Grunert recommended in some exceptional cases. 

Acute Sepsis 

Develops in some rare cases as a complication of suppuration of the 
middle ear. The clinical picture appears more like meningitis than like 
pyemia. 

It is peculiar that I observed this complication, which has a charac- 
teristic serious course leading rapidly to death, in a form of chronic sup- 
puration of the middle ear 1 which otherwise almost never leads to serious 
consequences, namely in cases with central perforation of the tym- 
panic membrane and a well preserved system of cells without cholestea- 
toma or caries necrotica. 

In two cases the entrance of water in bathing was the cause for the 
acute recurrence of the suppuration which leads to the fatal disease. In 
one case there was besides the acute recurrence an angina with false mem- 
branes in the follicles, in the other two an otitis externa crouposa. 

The whole surroundings of the ear become very painful when muco- 
purulent secretion appears in an old perforation of the tympanic mem- 
brane. A high febris continua developes. The pulse becomes rapid and 
small. Consciousness is considerably deranged -from the first few days 
on. The patients sleep very much and then become comatose and de- 
lirious during the next few days. 

Two of the three patients whom I observed died in a few days in 
spite of opening of the antrum and cells, which contained only little 
secretion but some fibrinous exudation and a lining that was somewhat 
swollen. The post-mortem showed a recent and only slightly developed 
phlebitis of the wall of the sinus and bulbus. The outer surface of the 



i Zeitschr. F. Ohr. Vol. 42, page 113. 



Otitic Abscess of the Brain. 237 

sinus was covered with a thin new layer of fibrin. Fresh embolic infarc- 
tions in the lungs were found in one case. The spleen was slightly en- 
larged corresponding to the short time the disease lasted. 

On account of the great rarity of these cases it seems to me that 
peculiar causes are here effective. 

Streptococci were found in the three cases. 

The cut in one case revealed very red and swollen lymph glands in 
the soft tissues on the mastoid process. 

The whole clinical picture suggests the idea that a simultaneous in- 
vasion of the lining of the middle ear and of the lymphatic system of 
the whole region takes place, which causes the wall of the sinus to be- 
come more rapidly and more easily permeable to infectious germs and 
toxines. 

I saw a very similar acute septic course in two other cases after a 
radical operation which was performed on account of cholesteatoma. A 
very painful lymphangitis developed in both cases from the sutures of 
the wound. 

Eulcnstein gave this disease the rather suitable name toxinemia 1 on 
account of the clinical picture which is very similar to that of pure poi- 
soning. 

The therapy of acute sepsis, which seems to have small chance of 
success, can consist only in uncovering the wall of the sinus as far as 
it appears red and covered with a fibrinous layer. 

3. Otitic Abscess of the Brain. 

It often offers the greatest difficulties for diagnosis. It is the most 
frequent cause of fatal termination of suppurations of the middle ear 
together with thrombophlebitis and leptomeningitis. An abscess of the 
brain is often found by mere good fortune in tracing a focus of disease 
from the ear. 

The number of cases of otitic abscesses of the brain which were op- 
erated upon during the last ten years is not much smaller than that of 
sinusthromboses. Koerner compiled only 55 operated abscesses of the 
brain in the first edition of his book (1893), while in the third edition 
(1901) he had 267 cases. 

The number of recoveries which Koerner found is not much smaller 
than that of sinusthrombosis. It amounts to 50.5 per cent in abscesses 
of the cerebrum and 52.8 per cent in abscesses of the cerebellum. 

The survey of that large material for observation led Koerner to 
draw the following conclusions, which are not less important for the 
pathogenesis than for our operative procedures. 

In the large majority of cases diseased bone extends from the mid- 
dle ear to the dura. The dura itself is visibly diseased in about half the 
cases. The diseased dura has almost always grown to the adjacent sur- 



1 "Ueber Toxinamie" Zeitschr. f. O. Vol. 40, part I. 



238 . Otitic Abscess of the Brain. 

face of the brain and a layer of a few millimeters of brain substance is 
as a rule between the adhesion and the brain abscess. 

It is by no means only the cases of chronic suppurations com- 
bined with cholesteatoma and caries which lead to abscess of the brain, 
but the number of observations increases steadily where acute suppura- 
tions terminate with the formation of an abscess of the brain, sometimes 
even after the suppuration in the middle ear has healed. 

The place where the suppuration transgresses from the middle ear 
through the meninges to the brain corresponds to the position of the 
abscess. In abscesses of the temporal lobe in the middle cerebral fossa 
the infection travels through the tegmen tympani and antri which often 
have dehiscencies. There are two avenues to the posterior cerebral fossa. 
Firstly, the superficial abscesses of the cerebellum generally form in the 
immediate vicinity of the sigmoid sinus, on a level with the mastoid an- 
trum. The sinus is usually also diseased in these cases. Secondly the 
deep abscesses of the cerebellum develop from the inner part of the pos- 
terior surface of the pyramid from an empyema of the saccus endolym- 
phaticus, or from a suppuration in the porus acusticus internus. The 
seat of an abscess in this region becomes so much more probable if a 
suppuration of the labyrinth can be diagnosed by means of the demon- 
stration of one-sided deafness. 

The otitic abscesses are twice as frequent in the cerebrum as in 
the cerebellum. 

Abscesses of the brain and especially of the cerebellum are much 
rarer in young children than in adults. Ear patients between n and 30 
years are in greatest danger. 

The symptoms of abscesses of the brain are so manifold and vary- 
ing that only a general sketch can be given. For further details I have 
to refer you to Koemer's book on this subject, which is indispensable to 
every busy practitioner. 

It is sometimes very difficult to find the cause for this serious clini- 
cal picture, consisting of rapid emaciation, almost always head-ache, de- 
pression and slowness of mental activity, etc., as almost all symptoms 
which might allow of a diagnosis are absent. Rise of temperature can 
be found only in the very beginning and then only in some cases. After- 
wards a long state of more or less complete latency takes place. Symp- 
toms of brain pressure appear later on and lead our diagnosis in a dis- 
tinct direction. They consist in slowness and irregularities of pulse or 
respiration, neuritis optica, partial simultaneous paralysis of the oculomo- 
tor and abducens nerves, caused by pressure on the base of the skull. 
In other cases there are more pronounced focal symptoms pointing to 
the locality of the abscesses, like paresis of the contralateral half of the 
body, sensoric aphasia, or, in abscesses of the cerebellum, cerebellar 
ataxia, vomiting, etc. 

Often enough it is only the terminal state, namely the perforation 



Otitic Abscess of the Brain. 239 

of the abscess into a ventricle or into the subarachnoidal space which 
makes the diagnosis clear and thereby decides the fate of the patient. 

Under such circumstances, gentlemen, you will recognize the great 
importance to the general practitioner of a thorough knowledge of the 
local symptoms which are characteristic for the serious forms of suppu- 
rations of the middle ear that threaten the general organism. 

These symptoms in acute suppurations of the middle ear are the long 
duration of the suppuration and the invasion of the labyrinth, which must 
be diagnosed by means of the functional tests; in chronic suppuration 
principally the location of the perforation. 

We need almost never think of fatal complications in chronic sup- 
purations with central perforation, be it ever so large. Every patient 
however who has a marginal perforation, especially if the entrance to 
the cells is narrow and there is cholesteatoma present, is in constant dan- 
ger of succumbing to some complication, as long as the fetor in the 
spaces of the middle ear can not be made to disappear completely and 
forever. 

The prognosis of abscess of the brain depends upon a number of 
points. A large number of abscesses are combined with other complica- 
tions, as sinusphlebitis and meningitis. Furthermore there are sometimes 
multiple abscesses. Some abscesses are inaccessible to the knife on ac- 
count of their position. I found for example in a post-mortem an otitic 
abscess on the medial surface of the occipital lobe, brought about by 
thrombosis of the sinus rectus. The number of otitic abscesses of the brain 
which are cured by operation is in spite of all that satisfactorily large, 
as the statistics of Kocrncr show. 

Gentlemen : — We can certainly expect that the number of deaths 
from otitic abscesses of the brain will be very much smaller in the future, 
when all suppurations which are not cured by conservative treatment 
and which suggest the possibility of complications are operated upon in 
time, and all avenues of suppuration followed up to the dangerous places. 

The abscess of the brain must be opened from fhe place from w T hich 
it developed. The bone must be removed, starting from the middle ear, 
as far as it is diseased, and to a sufficient extent for the opening of the 
dura. Sometimes there is already a small opening in the dura. Other- 
wise we may postpone the incision of the dura for a few days in order to 
ascertain whether the dangerous symptoms were not due to an extradural 
abscess which may have been present at the same time. The incision is 
made by means of Preysing's knife bent at a right angle. It must not 
enter deeper than 3 centimeters, neither must the drainage tube which is 
inserted after the pus is evacuated. The opening in the dura must be 
held apart by means of an anatomical forceps, in order to facilitate the 
evacuation of the pus, which has often gathered in a sinuate cavity, and is 
mixed with necrotic pieces of brain tissue. The incision in the dura must 
not be made larger than is necessary for the purpose of introducing a 



240 Otitic Leptomeningitis. 



thick drainage tube. Owing to this precaution I never saw the danger- 
ous picture of prolapse of the brain during the after-treatment; on the 
contrary I have witnessed die recovery of all the abscesses of the brain 
which I opened. 

I do not approve of exploratory incisions into the dura if it is found 
unchanged at the operation, unless there are reliable symptoms of the 
presence of an abscess in the region we are searching. 

4. Otitic Lepto Meningitis. 

It may, as we saw, start from an abscess of the brain which has per- 
forated into the ventricle, or into the arachnoidal space ; or it may start 
from any part of the thrombosed sinus, thus becoming the cause of death. 
Extradural abscess may lead to gangrene of the dura and infection of the 
pia if it lasts long enough. It originates most frequently from suppura- 
tion of the labyrinth, which finds open avenues to the arachnoidal space 
through the porus acusticus internus and through the aquaeductus coch- 
leae. 

Meningitis was the cause of death in a large number of cases that 
were operated with fatal termination. 

The impression prevailed that in a large number of fresh suppura- 
tions of the labyrinth the shock of chiseling was instrumental in spreading 
the suppuration to the pia mater. The luxation or the unintentional ex- 
traction of the stapes during awkward attempts at extraction of foreign 
bodies, or during scraping of granulations from the tympanic cavity 
proved several times to be the cause of fatal meningitis. 

Acute suppuration of the middle ear is complicated with meningitis" 
about as frequently as is chronic suppuration. 

The largest number of cases of otitic meningitis occur between the 
ages of ten and thirty, while children die comparatively rarely from it. 

Acute suppuration of the middle ear leads much more frequently to 
meningitis and death in patients over 40, than does chronic suppuration 
(16 to 5 cases in the statistics of Heine from Lucae's clinic 1 ). 

The diagnosis of a well developed diffuse lepto meningitis is not 
difficult, and you are acquainted with the symptoms which it produces. 

The decison is, however, impossible in many cases of beginning cir- 
cumscribed meningitis, especially if other cerebral complications are also 
present. 

An important differential diagnostic means is lumbar puncture. A pos- 
itive finding of abundant pus corpuscles and pathogenous organisms is 
always present in the fluid in well pronounced diffuse meningitis. The 
clinical picture in these cases is however sufficient for our diagnosis and 
will deter us from operating. 

The lumbar puncture may give a negative result in beginning cir- 
cumscribed meningitis, while on the other hand micro-organisms may be 



1 Berl. klin. Wochenschr. 1900, page 769. 



Tumors of the Brain. Meningitis Serosa, Tuberculosa. 241 

found in the fluid of a case of abscess of the brain which has no menin- 
gitis. 

Lumbar puncture can furthermore not be regarded as a diagnostic 
means which is void of all danger. The number of cases in which it 
accelerated death, is already large enough to caution against it unless it 
is urgently indicated. I saw death occur at the table after only a few 
cubic centimeters of lumbar fluid were withdrawn. It is true though, 
that the patient was moribund at the time of the operation. 

I need not explain furthermore what an amount of serious damage 
may be caused by the quick withdrawal of a large quantity of cerebro- 
spinal fluid in a case of fresh suppuration of the labyrinth, which had 
no time to form a protective wall of granulations in the porus acusticus 
internus and aquaeductus cochleae against the overflow of pus into the 
arachnoidal space. 

Considering finally the cases reported in literature, which were cured 
by operation of the fundamental disease in spite of beginning meningi- 
tis ascertained by lumbar puncture, we must not be deterred by the pos- 
itive result of lumbar puncture from operating such cases. These are 
the reasons why, together with other authors, I consider lumbar punc- 
ture for diagnostic purposes a superfluous operation in otology. 

"Meningitis serosa" is a term often used in order to explain a num- 
ber of cerebral symptoms occurring in the course of suppuration of the 
middle ear which disappear again. 

These cerebral symptoms in suppuration of the middle ear however 
do not show whether we are justified in setting up a separate clinical pic- 
ture under the name of meningitis serosa, as did Quincke. 

"Because" as Koerner remarked, "it was never the course, but 
the end of the disease which afterwards led us to enter such cases into 
the casuistic of meningo encephalitis serosa." We are always in doubt 
whether there was not a collateral oedema of the meninges and brain, or 
toxic influences, or a beginning suppurative leptomeningitis which re- 
mained circumscribed, that produced these symptoms. 

My own observation taught me that tuberculous meningitis and tuber- 
cles of the brain may start directly from the tuberculosis of the temporal 
bone. Tuberculosis in the ear, and tuberculosis inside the skull, develop 
separately in the large majority of cases, though from a common cause 
present in the organism. 

In differential diagnosis of meningitis and abscess of the brain we 
must also think of other tumors of the brain which occur more frequently 
in children than in adults. 

Finally we have to mention under the heading of complications of 
suppuration of the middle ear: 



16 



242 Hysteria in Suppuration of the Middle Ear. 

5. Hysteria in Suppuration of the Middle Ear. 

Hysteria has often induced colleagues to operate on the ear but of 
course in vain. We must therefore discuss it, although it is not really a 
consequence of suppuration of the middle ear. A few cases of traumatic 
neurosis, occurring especially in working people who are insured against 
accident, must also be mentioned. 

It is surprising how all details of the symptoms urgently necessitating 
an operation in diseases of the middle ear may be feigned especially by 
young hysterical women. Spontaneous pain, and pain on pressure around 
the ear are often declared to be enormous. Fetid discharge may be pro- 
duced by uncleanliness, increase of temperature by friction of the ther- 
mometer. Even disturbance of consciousness, dizziness, disturbance in 
the motility of the eyes, a difference in the pupils, etc., may be present. 

A female patient with acute suppuration of the middle ear was 
brought to me in a comatose condition which had lasted for several hours. 
She woke up during semi-narcosis, and was later on proved to be hyster- 
ical. 

The finding at the operation in such cases usually suggests that we 
were deceived. 

Such patients usually urge an operation not only once, but hardly 
are they cured in one clinic, when they repeat the performance with a 
second and third surgeon. Cases became known which had gone through 
a number of serious operations on both ears. 

We can avoid similar mistakes by very carefully considering the ob- 
jective findings in the ear. They often allow us to exclude at once serious 
complications, as for example in simple central perforations, or in cases 
which have a wide open entrance to the antrum and cells. 

The location of the sensitiveness to pressure also does not usually 
coincide with our experience in similar cases. The hyperesthesia of the 
skin may be equally spread over the whole surroundings of the ear. The 
answers finally to hearing tests are often such as can not possibly be 
accurate. There are therefore a number of points which may reveal the 
true state of affairs. 



LECTURE XXV. 

Residues of Otitis Media Purulenta with Persistent 

and with Healed Perforations of the 

Tympanic Membrane. 

Gentlemen: — We find the residues of former suppurations of the 
middle-ear to be the cause of deafness in nearly 10 per cent of all ear 
patients whom we have to examine (in my statistics they were 9.5%). 
The suppuration has stopped and the examination by means of the spec- 
ulum reveals either a persistent dry perforation, or a scar in the tym- 
panic membrane. 

Children are represented in my statistics by 17.3 per cent, adults by 
82.7 per cent. 

The residues concerned both ears in 534 per cent, one ear in 46.6 
per cent of cases. The perforation in the tympanic membrane was closed, 
leaving a scar in 944 cases of residues out of 1,937 which I compiled, or 
in nearly half of all cases. These figures furnish the proof for the fact 
that many perforations close later on by forming scars, even a number of 
years after we have ceased observing them. The more or less extensive 
perforations in chronic suppurations of the middle ear may also heal 
later than it is usually necessary for us to control them. 

A. Dry Persistent Perforations. 

They are just as diverse as to size and form as those which we see 
during the suppuration (compare the plate of tympanic membranes fig. 
6, 7) 8). 

The only subjective symptom which is never absent in dry perfora- 
tions is the decrease of the power of hearing. Subjective noises are so 
rare that we must attribute them to other causes than the perforation 
whenever they are present. 

The power of hearing for speech varies greatly. On an average 
it is only moderately diminished. Among the 1,807 children which I saw 
during my examinations of school children there were 35 dry perfora- 
tions. Of these organs of hearing 21 understood whisper at a distance 
exceeding 4 meters, five of them exceeding 16 meters. 

243 



244 Residues with Persistent Perforations of the Tympanic Membrane. 

The hearing of tones shows two pronounced changes in all cases 
of perforation of the tympanic membrane. Firstly, there is a defect of 
hearing by air conduction of tones of lowest pitch. The extent of 
this defect varies with the size and position of the perforation. The 
defect diminishes and disappears, the higher we rise in pitch. Secondly, 
there is a prolongation of the duration of hearing by bone-conduction 
which becomes more pronounced, the lower in the scale we descend. 

This condition which we find in all cases that have visible defects 
of the sound-conducting apparatus permits us to draw the following fun- 
damental conclusion as to the function of the sound-conducting apparatus, 
namely, that this apparatus is necessary for the transmission of the sounds 
of the lowest part of the sound scale from the air to the labyrinth. On 
the other hand we are now justified in drawing conclusions as to defects 
or abnormities of the invisible parts of the sound-conducting apparatus 
in cases where the tympanic membrane appears intact, providing the 
above mentioned functional disturbances are present. We draw the 
opposite conclusion, namely, that the function of tne sound-conducting 
apparatus remains intact, if an ear hears all sounds down to the lowest 
pitch perfectly, and there is no prolongation of bone conduction. We 
shall discuss the great importance of these conclusions for our diagnosis 
in speaking about the numerous diseases of the ear with negative finding 
of the tympanic membrane. 

We are able to produce a considerable improvement of hearing in 
many cases of defects of the tympanic membrane by the insertion of a 
so-called "artificial tympanic membrane" consisting of a piece of rubber 
with a small guiding rod or tube which is pressed against the defect. 

Yearsley in 1848 obtained the same effect by means of a small moist 
ball of cotton which he inserted into the defect. It seems that the ma- 
jority of authors return to this simple device which has since been modi- 
fied in many ways. 

The improvement of hearing produced by the ball of cotton seems 
to be brought about exclusively by the pressure it exerts. 

There are so far only very unsatisfactory explanations for the 
mechanism of this physiological effect. 

I think however that we can understand it if we remember the an- 
tagonism of the two muscles in the middle ear (compare page 49). 
I recognized an improving effect of Yearsley 's ball of cotton only in those 
cases which had an isolated stapes left together with the tendon of the 
stapedius muscle, and only under the condition that the isolated head 
of the stapes is pressed inward by the ball of cotton. We saw that the 
main condition for the transmission of the minutest changes of air pres- 
sure is that the whole intact sound-conducting apparatus be ex- 
tremely well balanced. This result is produced by the traction of the 
stapedius muscle pulling the superior anterior periphery of the foot-plate 
outward, thereby stretching the ligamentum annulare which is especially 



Residues with Persistent Perforations of the Tympanic Membrane. 245 

broad at this part of the periphery. At the same time the expansion is 
counteracted by the tensor tympani muscle which pushes the head of the 
stapes inward. Suppose now this latter effect is lost on account of the 
separation of the incus from the stapes, or on account of total absence of 
the incus, then the pressure upon the head of the stapes exerted by the 
traction of the tensor may under normal conditions be replaced to some 
extent by the pressure of an elastic ball of cotton. In this manner we 
may understand that the footplate of the stapes, which was held fast in 
an extreme outward position by the traction of the stapedius muscles, be- 
comes more movable and can therefore follow the impulses transmitted to 
it by the sound waves. 

Two objections may be raised against this explanation of the improv- 
ing effect of the ball of cotton. The first one is that in a large number 
of cases the long process of the incus is absent, that the head of the stapes 
is isolated, and as such visible, and that, in spite of this fact, there is con- 
siderable power of hearing. The second, that only in a small fraction of 
such cases a pronounced improvement of hearing can be produced. 

You will however readily understand that exactly the same improve- 
ment of hearing as by means of the ball of cotton can result from tight 
adhesions running forward from the head of the stapes, thus counteract- 
ing the traction of the stapedius muscle. The result of these adhesions will 
be much more effective if they run from the head of the stapes to a rem- 
nant of the tympanic membrane, which is still able to vibrate, and to the 
handle of the hammer which is drawn inward by the action of the tensor 
muscle. These conditions can be recognized with our eyes, and we often 
find an astonishingly good power of hearing in cases which show them. 

All these considerations are not alone of theoretical but of great 
practical importance. 

It was often recommended to make the isolated stapes more movable 
by cutting such adhesions. You will hesitate, gentlemen, to perform 
such a circumcision of the stapes in cases which have preserved a certain 
amount of their power of hearing, if you consider the valuable part 
which some of those adhesions play, even though in one case or another 
you may have acquired an improvement of hearing by it. 

We see how small the pressure upon the stapes needs to be in order 
to produce an improvement of hearing in the numerous cases of chronic 
suppuration, who hear better while there is secretion than after it has 
stopped. The thin layer of fluid weighing upon the stapes proves 
adequate to favorably influence the power of hearing. The same result 
may be acquired by means of a drop of water. 

We can not however recommend the constant wearing of a ball of 
cotton, especially if its insertion is left to the patient. It may involve dan- 
gers as long as there is still some suppuration, and lead even to necrosis 
of the bony walls, as the case shows which was reported on page 217. 

The simple forcible inflation of boric acid powder after the region 



246 Residues with Persistent Perforation. 

of the stapes is moistened, is often sufficient in order to produce the 
improvements of hearing in cases which do not need high pressure upon 
the stapes. The improvement after these inflations sometimes remains 
for weeks. 

A permanent perforation of the tympanic membrane requires special 
precautions in order to keep harmful influences from entering from the 
outside into the wide open spaces of the middle ear. 

A drop of water entering into the tympanic cavity may produce a 
renewal of a suppuration which had long disappeared. In diving, water 
may enter the tympanic cavity through the perforation as well as through 
the nose and the tube, much more easily than if the membrane is closed. 
On page 237 I described two cases of general sepsis terminating fatally, 
which followed a similar recurrence after a bath. They demonstrate how 
dangerous such an acute recurrence of the suppuration may be in an ear 
which is practically normal except for the perforation of the tympanic 
membrane ; that is a middle ear with well developed pneumatic cells, etc. 

Patients with perforations of the tympanic membrane ought there- 
fore to protect their ears by water tight caps and remain under water 
only during expiration, since only for that length of time does the nose 
remain free from water. 

The cartilaginous meatus ought to be lightly closed by means of a 
piece of cotton in order to keep out dust and the influences of tempera- 
ture. The patient ought to be cautioned against all kinds of interference, 
like inserting strips of gauze by means of forceps, etc., into the bony mea- 
tus, on account of the thin lining in this part of the canal which is so eas- 
ily injured. 

Marginal perforations on the posterior and anterior superior peri- 
phery of the tympanic membrane and perforations of Shrapnell's mem- 
brane ought always be controlled by the surgeon once every three to six 
months, even after the suppuration has ceased. Dry crusts develop from 
time to time either on the margin of the perforation or in the whole per- 
foration, and brownish masses of epidermis appear. Large solid masses 
of epidermis can sometimes be removed by means of a forceps, if the 
crusts are first carefully loosened all along the margin by means of a 
probe. These masses of epidermis are sometimes so large that they must 
have reached into the antrum and are pure white and moist on the in- 
side. 

A few direct injections by means of the antrum tube and insufflations 
of boric acid are often sufficient to keep the cavity dry for months and 
years if the masses are removed in time. Granulations will form around 
the masses and the epidermis will decompose if it is not removed, and all 
the well known, manifold dangers which are more peculiar to 
cholesteatoma than to any other form of suppurations of the middle ear, 
threaten the patient. 



Residues with Healed Perforations. 247 

B. Residues with Healed Perforations of the 
Tympanic Membrane. 

Daily experience teaches that simple perforations of the tympanic 
membrane of any size may under favorable conditions heal by formation 
of a scar. It is not a rare occurrence that we find a scar in place of the 
whole tympanic membrane which contains neither handle nor the short 
process of the hammer. I found such scars repeatedly in patients who 
had the whole tympanic membrane excised together with the hammer and 
the incus by a surgeon who intended thereby to improve hearing. 

Such scars can be easily recognized by the eye on account of their 
sharp limits and their dark color (compare the pictures of the membrane 
figs. 12 and 13) . They are often partially framed by white, clearly defined 
incrustations of lime. Such incrustations of lime in the membrane are 
often the only residues of suppurations of the middle ear which have run 
their course. 

The scars can not always be distinguished from circumscribed atro- 
phic parts of the membrane which are found in occlusion of the tubes that 
has lasted for many years. 

The retraction is often so pronounced in very thin scars and in 
atrophy of the membrane, that the impression of a total absence of the 
membrane is produced. The movements of the scar inward and outward 
can however easily be recognized if the air in the external meatus is 
rarefied and compressed by means of Siegle's otoscope or Delstanche's 
rarefactor. 

No treatment of a well developed scar is necessary. Inflations of air 
whenever they become indicated on account of occlusion of the tubes or 
gathering of serum, etc., must be given with low pressure only, as scars 
and atrophic parts burst easily. 

The formation of a scar, i. e., the closing of a perforation that is 
not too large, and not marginal, can be induced by systematical cauteri- 
zations of the margin of the perforation by means of the crystal water of 
trichloracetic acid (Okuneff). It is applied by means of a probe wrapped 
with cotton. A continuation of this treatment is of no avail if the size 
of the opening does not diminish after 6 to 10 applications given at inter- 
vals of 2 to 3 days. 

Otitis Media Simplex Chronica. 

(Chronic Simple Catarrh of the Ears According to Von Troeltsch.) 

We discussed a large number of diseases of the middle ear under the 
headings "occlusion of the tubes" "occlusion of the tubes with gathering 
of serum" and "occlusion of the tubes with atrophic tympanic membrane," 
which show a well characterized sharply circumscribed clinical picture. 
I think I am justified in recording them separately in the clinical statistics. 
The diagnosis "chronic catarrh of the ear" suffered another considerable 



248 Otitis Media Simplex Chronica. 

restriction when the formerly so-called "dry catarrh of the ear" (otoscle- 
rosis) revealed itself as a disease which is not at all located in the lining 
of the tympanic cavity, and therefore is certainly not entitled to the name 
"catarrh." This fact was foreseen long ago by v. Troeltsch and has 
been verified lately by a large number of coinciding pathologic anatom- 
ical investigations. v. Troeltsch taught furthermore that there are 
often a number of changes in the tympanic membrane which are consid- 
ered characteristic for chronic catarrh of the middle ear combined with 
nearly normal hearing. Only an accurate functional test of the ear will 
decide whether hard hearing is really caused by serious changes in the 
tympanic cavity corresponding to the visible changes in the tympanic 
membrane. The methods of testing the hearing of sounds by air and 
bone conduction have been improved in so many different directions since 
the time of v. Troeltsch that they show how often the main and even 
the exclusive cause of the disturbance of function is beyond the middle 
ear, in the labyrinth, etc., in spite of pronounced anomalies of the tym- 
panic membrane. 

The diagnosis otitis media simplex chronica is today justified only in 
cases which, besides the characteristic findings of the membrane, present 
also those functional symptoms that were so far shown to be the effect of a 
disturbance of the sound-conducting apparatus. 

The long duration of hard hearing and the absence of symptoms of 
fresh inflammation are important factors for this diagnosis. In the find- 
ings of the tympanic membrane we must lay especial stress upon the per- 
manent changes caused by processes in the tubes which lasted for many 
years, or remained after repeated acute and subacute attacks of inflamma- 
tion. 

Otitis media simplex chronica differs from the diseases which are 
more or less confined to the tube, in that an opening of the tube by means 
of inflation does not produce the startling improvement in hearing, namely 
twenty times that of the previous distance, which was given as the main 
criterion of a more or less pure affection of the tubes. 

A prominence of the short process, and the posterior fold extending 
from it backward and downward as a fold in the membrane, are the 
most frequent characteristic symptoms of retraction remaining after long 
lasting affection of the tubes. The posterior fold is often changed into a 
whitish streak which we may designate as the "posterior cloudy mark." 
It often continues downward to an accentuated cloudiness in the interme- 
diary zone, extending more or less around the handle of the hammer. The 
tympanic membrane in chronic otitis media simplex shows different 
degrees of diffuse cloudiness, contrary to the characteristic dark color in 
fresh processes of the tubes. 

Hard hearing undoubtedly in these diseases is principally due to ad- 
hesions between the chain of ossicles, the walls of the tympanic cavity, 
and the tympanic membrane, which remained after repeated attacks of in- 



Dysacusis. 249 



flammation. They were therefore called "chronic adhesive processes in 
the middle ear." We can sometimes recognize such adhesions on the tym- 
panic membrane. The head of the stapes especially is often adherent to 
the posterior superior quadrant of the tympanic membrane, and is either 
isolated or still connected with the long process of the incus. The handle 
of the mallet often looks clumsy and is removed backward while Shrap- 
nell's membrane appears adherent to the neck of the hammer, etc. 

The presence of secretion in the tympanic cavity can often be estab- 
lished by means of noises heard in auscultation during inflation through 
the catheter, if there is still occlusion of the tubes. Such cases are acces- 
sible to moderate improvement of hearing if inflation is continued for 
some time. 

In my statistics patients suffering from the disease amount to 3.4 
per cent of all ear patients. This figure is at present rather too large than 
too small since we have learned to distinguish more accurately by means 
of functional tests. Children are represented in this figure by 14 per cent. 
Both ears are affected in 88 per cent of these cases. 

Dysacusis. 

The functional findings in a certain number of hard hearing people 
do not warrant a sharp discrimination between disease of the middle 
and inner ear. The answers to our functional tests are sometimes not 
sufficiently reliable to use them for diagnostic purposes, as for example 
in imbeciles, or in pronounced hysterics, or in patients who are liable to 
sham for personal interests (e. g. on account of accident insurance). 
In some cases we have to allow for a simultaneous disease of the middle 
and inner ear according to our hearing tests. 

The term "dysacusis" was chosen in order to classify all those heter- 
ogenous forms of chronic hard hearing whose origin can not be definitely 
ascertained. This expression is not supposed to confer any meaning as 
to the nature of the disease which is the cause of the deafness, but simply 
means that we are unable to establish a definite diagnosis. The sum total 
of these cases in my statistics is 4.2 per cent of all ear patients. 



LECTURE XXVI. 

Otosclerosis. 

Gentlemen: — There is a comparatively large number of hard hear- 
ing people whose tympanic membrane appears normal as to form and 
color, contrary to the findings in otitis media simplex chronica just de- 
scribed. A mild diffuse redness of the intermediary zone of the mem- 
brane is found in some exceptional cases and must be explained as an 
injection of the promontory seen through the membrane (Schzvartze). 
By means of the auscultation tube we hear the air inflated through the 
catheter, bound against the tympanic membrane in a continual weak, me- 
dium or strong current, the same as in a normal ear. Whenever I applied 
posterior rhinoscopy in these cases the ostium pharyngeum of the tube 
was always found normal. 

The functional tests for hearing by air and bone conduction in spite 
of the negative findings of the tympanic membrane and the middle ear 
reveal all the well known symptoms which are characteristic for an inter- 
ference of motion and a fixation of the sound-conducting chain. This is 
the case in such a typical manner, even in patients whose hearing of 
speech is very little impaired, that the functional tests alone suggest that 
the lever apparatus must be damaged at the most effective spot of the 
sound-conducting chain, namely the stapes. 

In 1857 Toynbee reported in his ''Descriptive Catalogue" that among 
1,149 specimens of temporal bones he found 126 cases of bony adhesion 
of the stapes to the oval window. 

Comparative hearing tests carefully carried out for air and bone con- 
duction over a period of many years convinced me that there are numer- 
ous hard hearing people who show characteristic functional symptoms 
which, with almost absolute certainty, pointed to fixation of the stapes. I 
showed for the first time in 1885 the pathologic anatomical proof that 
ancylosis of the stapes is the real cause for this complex of functional 
symptoms. 

The patient was a man who had suffered from sclerosis of both ears 
for 16 years, and consequently from continual subjective noises which 

250 



Otosclerosis. 251 



ultimately caused him to commit suicide. By means of manometric meas- 
urements in the manner before described (page 14) I could prove the 
absolute immobility of the stapes. The temporal bone, after it had been 
macerated, showed fixation of the foot-plate of the stapes from ossifica- 
tion of the lig. annulare. 

A large number of investigators since then established by anatomical 
examination of a great many cases, that ancylosis of the stapes is the 
anatomical cause for the peculiar findings at the examination with tuning 
forks in otosclerosis. We shall now enter into a discussion of these find- 
ings. Katz made the first histological examination. It showed like the 
next four examinations, which were made by myself and Scheibe, partial 
or complete bony ancylosis of the foot-plate of the stapes. 

The real scat of the disease is the bony capsula of the labyrinth as 
Politzcr was able to ascertain from numerous cases which he examined. 
The periosteum of the promontory also seems to be not infrequently 
involved in the disease. Sometimes a number of isolated foci of the 
disease are distributed over the whole capsula of the cochlea and the other 
parts of the labyrinth, as far as the porus acusticus internus (Sieben- 
mann). The foci are found most frequently in the bony frame of the foot 
plate of the stapes, and in the foot-plate itself, which often appears in- 
creased to ten times and more its original thickness. The niche of the 
oval window together with the stapes may in very far progressed cases 
be found filled with new formed bone tissue (Politzer). 

Very vascular osteoid substance containing a great many giant cells 
was found in fresh cases in place of the compact bone in the normal cap- 
sula of the labyrinth, in other places rows of osteoblasts were met with. 
Spongy bonesubstance remains wherever the process has run its course 
The margin of the window is often connected with the foot-plate by a 
number of bony bridges. 

We do not know of any analogy in the pathology of our system of 
bones for this chronic inflammatory, hyperplastic process, as we must 
call it on account of its anatomical peculiarities. Etiology does not fur- 
nish an adequate explanation either. A connection with lues or with some 
other general dyscrasia was suggested by many authors. I must refute 
this connection, judging from my many years of experience in more than 
1,000 cases. Most of these patients appear perfectly healthy otherwise. 
All these facts notwithstanding, there can be no doubt but that the gen- 
eral constitution of the patient furnishes the main basis for this disease 
and that it can not be attributed to a merely local harmful influence affect- 
ing exclusively the ear. This fact is shown by the following statistics : 

No disease affects both ears as frequently as sclerosis. According to 
my statistics both ears are affected in 88.8 per cent of all cases, and later 
investigators obtained similar figures. 

Patients comparatively often attribute an increase of hard Hearing to 
childbed though only exceptionally its beginning. 



252 Otosclerosis. 



The beginning of hard hearing sets in between the 20th and 50th 
year of life in the majority of cases. Only 3.5 per cent of all cases of 
otosclerosis could be shown to have existed in children under 15 years of 
age. 

All authors agree as to the great frequency of heredity of sclerosis. 
In nearly 52 per cent of my cases I obtained positive information that 
one or several members of the same family, sometimes whole series of 
relatives, were hard of hearing. 

Another fact is still more peculiar. This form of hard hearing con- 
cerns especially the female sex, contrary to all other diseases of the ear. 
Only 42 per cent of all ear patients were women while 57.4 to 66.1 per 
cent of all patients suffering from sclerosis were female, according to 
my records of the last three years with which the records of other authors 
coincide. , 

The statistics therefore open a view into dark influences dating very 
far back. We can hardly expect that the pathogenesis of this peculiar 
disease will ever be satisfactorily explained, so much more so, as its clin- 
ical and pathological picture has no analogy. 

Seven per cent of all ear patients suffered from otosclerosis. 

The most important part of our diagnosis is to distinguish sclerosis 
from those diseases of the inner ear which, like sclerosis, show no 
changes of the tympanic membrane or of the middle ear at our examina- 
tions of the living. 

We learned how to accurately distinguish one from the other by 
means of functional tests of the ear. 

We proceed in the following manner : 

1. The power of hearing is ascertained by whispering numbers 
(1 to 99) at various distances after forced expiration. The shortest dis- 
tance and the numbers that are heard the least are recorded. 

It is peculiar for this test that those sounds of speech which lie deep 
in the sound scale are poorly heard as compared to the high ones. We 
ordinarily exclude the word "100" on account of its very close range of 
hearing, and use it only once in a while. The numbers "one," "two" and 
"four" and especially their combinations "forty-four," "forty-two" and 
"forty-one" are the hardest to perceive, while "three," "six," "seven" are 
accurately heard at comparatively large distances. The continuation of 
the hearing tests by means of the tuning forks, etc., showed that our diag- 
nosis was often turned in the right direction as the result of this test by 
speech. 

2. We were able to establish a pronounced shortening of hearing 
by air conduction at the lower end of the sound scale in all visible changes 
of the sound-conducting chain, beginning from the smallest traumatic 
perforation of the tympanic membrane to the most extensive destruction 
of the ossicles. This fact, which was ascertained without exception, led 
us to conclude that the function of the sound-conducting chain consists 



Otosclerosis. 253 



in the transmission of the lowest part of the sound scale from the air to 
the fluid of the labyrinth. 

Hearing by air conduction of the lowest tuning forks of the con- 
tinuous series without overtones, is particularly interfered with in sclero- 
sis. Hearing by air conduction of the forks from 12 to 36 double vibra- 
tions, representing the lowest normally heard one and one-half octaves, 
is completely lost, even in cases which show only a slightly diminished 
hearing for speech. The loss of hearing at the lower part of the sound 
scale increases with the increase of hard hearing for speech. Patients 
with sclerosis who hear conversation only partially, and close to the ear, 
have often lost all hearing up to the middle of the one stroked octave, 
and the first sound heard by air conduction is g' which is equal to a loss 
of nearly five octaves. 

The determination of the lowest sound which is barely perceived by 
air conduction by means of the weighted tuning fork is therefore one of 
the most important points for our diagnosis. We are not justified in diag- 
nosing a fixation of the stapes in patients who hear by air conduction 
below 32 v. d., and ought to look for another explanation of hard hear- 
ing. 

3. We had occasion to establish a prolongation of bone conduction 
for the lower part of the sound scale in different interferences of the 
sound-conducting apparatus, just as regularly as a shortening by air con- 
duction. We test the duration of bone conduction in the lower part of 
the scale by means of the A tuning fork. 

We are justified in diagnosing sclerosis only in such patients who 
hear this tuning fork, placed on the vertex, longer than a person with 
normal hearing {Schwabach's test compare page 67). Patients who 
sustained a fracture of the skull at some previous period of their life must 
be excepted, as their hearing by bone conduction may be considerably 
shortened although their hearing by air conduction is absolutely normal. 

4. Sometimes we find the duration of bone conduction in sclerosis 
prolonged, but also, not very rarely, somewhat shortened in testing by 
means of a' which is two octaves higher than A. I shall give you the 
explanation for this later on. 

5. We compare the duration of bone conduction with that of air 
conduction by means of an a' tuning fork {Rhine's test). The handle 
of the fork is first set on the mastoid process till the sound has died away 
whereupon the prongs are held before the meatus till the sound has died 
there also. The sound is heard 30 seconds longer by air conduction in 
the normal ear. In sclerosis, Rhine's test is negative, i. e., bone conduc- 
tion is either just as long as air conduction {Rhine's test ±0) or is even 
longer by a few seconds (in extreme cases 15 seconds and more). 

6. Sounds of highest pitch tested in air conduction by means of 
Gait oil's whistle are sometimes heard normally. I could not affirm that 
higher sounds than normal could be heard in the initial state of sclerosis 



254 Otosclerosis. 



(Zwaardemaker) nor could Siebenmann and others. A considerable loss 
at the upper limit is, however, frequent, especially in advanced cases. In 
a certain number of patients who were very hard of hearing on account 
of sclerosis I found besides this nearly constant defect at the upper limit 
of the sound scale, a well circumscribed gap of hearing a little lower but 
still within the region of Galton's whistle. 

We are involuntarily reminded of the multiple isolated foci of ostitis 
in the capsule of the cochlea which Siebenmann found histologically in 
sclerosis. You will appreciate, gentlemen, the new and beautiful affirma- 
tion of v. Helmholtz's theory contained in the finding of hearing just 
described. According to this theory the perception of the whole scale of 
sounds is distributed over the entire scale of the cochlea. Beginning 
with the highest sounds in the basal coil, therefore in the immediate neigh- 
borhood of the original focus at the foot-plate of the stapes, the perception 
extends downward in pitch to the cupola. You will furthermore under- 
stand why there is not infrequently a decrease of hearing in the middle 
of the scale for a' as I have explained to you. This decrease must be 
attributed to the inner ear, as it concerns bone conduction also. 

The following triad of functional symptoms, in addition to normal 
or nearly normal finding on the tympanic membrane and cavity, is neces- 
sary in order to diagnose otosclerosis (ancylosis of the stapes). 

I. Loss of hearing by air conduction for a considerable part at the 
lower end of the tone series. 

II. Prolongation of bone conduction above the normal duration for 
tuning fork A. 

III. Negative Rhine's test for tuning fork a'. 

We find furthermore no response to inflation of air, neither through 
the catheter nor by means of Politzer's method. Sometimes we notice 
an insignificant decrease or an equally insignificant improvement of hear- 
ing after inflation. They are explained by the inaccuracy of our examina- 
tion of hearing by means of speech. 

Two symptoms must be mentioned which occur frequently in sclero- 
sis, the first is subjective noise the second dizziness. 

According to my statistics, 22 to 32 per cent of patients suffering 
from sclerosis complain about dizziness. It is however only exceptionally 
so pronounced that the patients lose their equilibrium and fall to the 
floor, or that retching occurs, as is often the case in affections of the 
inner ear. The statement is sometimes made that dizziness is noticed in 
stooping. 

The subjective noises in the ear and head are mucn more disagree- 
able to the patient. They occur either temporarily or permanently in jj 
to 78 per cent of all patients suffering from sclerosis. 44 to 46 per cent 
of patients suffer from it continually ; many sensitive patients can hardly 
stand it. The character of the noise is described as whistling, ringing, 
rushing like escaping steam, more rarely as of boiling water or chirping, 



Otosclerosis. 255 



in other words the noise may be of high or low pitch. Their variety in 
pitch and intensity however does not seem to be as great as in diseases of 
the inner ear. 

The subjective noises may be attributed to vascular murmurs, which 
in the diseased ear are conducted to the labyrinth so much more easily 
than in the normal ear, on account of the tightened fibres of the sound- 
conducting apparatus, similar to the sound of the timing fork placed on 
the vertex ; or they may be explained by the transmission to Corti's organ 
of the murmurs of the blood vessels which are much louder in the highly 
vascular foci of the disease in the capsula of the labyrinth than in the 
normal. The latter explanation must be favored for the reason that a 
high tension of the ligamentum annulare occurs also in large defects of 
the tympanic membrane, on account of the preponderance in traction of 
the tensor muscle, or in cases with isolated stapes on account of the 
traction of the stapedius muscle; still no subjective noises are complained 
of as a rule. A third possibility is that these noises are caused by patho- 
logical processes in Corti's organ itself, like changes of tension, etc., 
which often become evident in the later stages, especially by the forma- 
tion of gaps of hearing in the region tested by means of Galton's whistle. 

The symptom of dizziness also finds its explanation by attributing 
it to a disease of the capsula of the labyrinth in the vestibulum and in the 
semicircular canals. 

Another symptom is often mentioned by patients suffering irom scle- 
rosis in common with other diseases of the middl-e ear. These patients 
understand speech better while traveling in a carriage or a train, or while 
surrounded by the din of a noisy machine shop, or while the drum is 
played, etc., than if everything is quiet (paracusis Willisii). Under the 
influence of noise a decrease of hearing for speech is on the contrary 
noticed in affections of the inner ear. It is therefore probable that a 
partially immovable sound-conducting apparatus is more sensitive to 
weaker impulses during the time when a shaking of the whole body keeps 
it vibrating. 

Gentlemen: — The prognosis as to complete recovery, or even consid- 
erable improvement of hearing can not be favorable if we remember the 
anatomical condition in otosclerosis. On the other hand our experience 
teaches that a large number of cases become stationary, with a moderate 
degree of hard hearing, rendering conversation possible. 

The term "progressive deafness" which is often used for sclerosis is 
therefore not justified. There is only a minority of exceptional cases 
where hard hearing progresses within a few years to such a degree as to 
make it difficult or impossible for the patient to understand conversation 
close to the ear. (The findings of Politzer where the whole niche of the 
oval window was filled with bone, belonged to very old inmates of the 
poor house. We only exceptionally have occasion to make a functional 
examination during life of cases which have progressed to such a de- 
gree.) 



256 Otosclerosis. 



An especially bad prognosis must be given in cases which continually 
show the transparent redness of the promontory, and furthermore in 
those with a considerable loss of hearing at the upper limit, and especially 
those cases which show gaps of hearing in the region tested by means of 
Galton's whistle. 

We can never predict a decrease of hearing. It is therefore our 
duty to be careful as to what we say to the patient, who often sees his 
future altogether too dark on account of the depressing influence of 
the subjective noises. It is true we can never promise an improvement 
of hearing, but must consider the psychic effect of our prognosis. It 
eases the mind of many patients to hear from an authority that they will 
not become deaf, and that it is very likely that their condition will remain 
stationary. It is, however, advisable to direct the patients to practice lip 
reading, which will greatly facilitate the understanding of speech should 
they become very deaf. To a patient who understands conversation only 
close to the ear I found a hand mirror of great advantage because it en- 
ables him to watch the mouth of the speaker who is talking close to the 
ear. I introduced this method very successfully in Munich into the 
course of instruction of deaf-mutes who have remnants of hearing. 

A speaking tube can not be dispensed with by patients who do not 
accurately understand whisper close to the ear. 

You can improve the gloomy frame of mind of many patients by 
assuring them that the noise in their head does not indicate some disease 
of the brain. This care weighs on many patients who do not explicitly 
inquire about this possibility. 

The psychic influence of a trusted physician upon such incurable 
patients is often the only thing that is able to give back to them their 
vital energy. In this manner you have done them much more good than 
if you try to deceive yourself and them as to their future by a series of 
attempts at treatment extended over a long time. 

Methods of treatment recommended against otosclerosis are very 
numerous as is usual against inaccessible diseases. A large number of 
operations were advised and generally discarded as useless, often harm- 
ful. They consisted in forming an artificial opening in the tympanic 
membrane, tenotomy of the tensor tympani and stapedius muscles, ex- 
traction of the malleus, the incus and even the stapes, etc. Politzer rec- 
ommends a temporary administration of iodide of potassium in early 
cases of sclerosis. Siebenmann advises the internal use of small doses of 
phosphorus to be taken many years, in the form of Kassowitz's emulsion 
(0.01:100) 1 to 2 tablespoonfuls a day. Neither Politzer nor Sieben- 
mann expect an improvement, but merely a checking of the progress. 
It is difficult to gain a judgment as to the effect of this medication since 
conclusions can be drawn only after many years and since a large num- 
ber of cases without treatment remain stationary for years or become 
very little worse. 



Otosclerosis. 257 



It is advisable to examine the hearing and ears of these patients at 
long intervals of time. By means of inflation of air we ascertain whether 
there are not some general catarrhal symptoms, or an exudation in the 
middle ear, etc. These processes have a detrimental influence upon the 
main disease although they are otherwise independent. To hear from 
their physician about every six months that their power of hearing has 
not decreased, but remained the same, eases the mind of the patients, who 
usually suffer from the impression that they perceive a progress of deaf- 
ness. 

Pneumomassage by means of an air pump worked by electricity was 
repeatedly recommended to alleviate the subjective noises. They often 
disappear for a short time, but its prolonged use may have a bad influ- 
ence on hearing. 

The ringing in the ears sometimes ceases from most peculiar causes, 
as the following example will show : 

In a case of otitis media simplex chronica I burned the hypertrophic 
rear end of a turbinal by means of the galvanocautery. The patient came 
to me the next day with the happy news that the ringing in his ear, which 
had continually bothered him for many years, had disappeared. I asked 
him whether this had never happened before for a day or so, when he 
answered that it had occurred but once directly after he had cut his 
thumb very badly. 

The real cause both times was probably the shock to the vasocon- 
stricting nerves which unfortunately can not always be produced at will. 

In habitual congestions in the head, derivatives to the bowels, so- 
journs at some bathing place, or hot foot baths taken in the evening, at 
intervals, may be of use. 

The patient suffering from otosclerosis feels best on high mountains, 
while it is a matter of experience that sea baths and cold douches to the 
head have a bad influence and ought to be avoided. 



17 



LECTURE XXVII. 
Otalgia. 

Neuralgia of the ears occurs rather frequently owing to the abun- 
dant sensory innervation of the external and middle ear. You know 
that acute inflammatory processes of the external and middle ear, which 
are accompanied by pain, can easily be recognized at our inspection of the 
external meatus and the tympanic membrane. The presence of exuda- 
tions in the middle ear may be ascertained by means of auscultation during 
inflation of air. The diagnosis of otalgia must be made only if all in- 
flammatory symptoms are absent. 

In my statistics I counted as otalgia only those cases that did not 
show a diminution of hearing. They amounted nevertheless to 2.7 per 
cent of all ear patients. Children were represented by 22.7 per cent. 
Both ears were affected in 15.3 per cent. 

Inflammatory processes in distant organs are, in the majority of cases, 
the cause of the pain, attributed by the patient to the ear. 

Otalgia was induced by caries of a tooth on the same side in about 
50 per cent of my cases (the perforation of the wisdom tooth also may 
produce ear-ache), in 10 per cent by angina, and in 2 per cent by affec- 
tions of the larynx. Otalgia may even be found as a symptom of proso- 
palgia. Pain located in front of the tragus and increasing in chewing- 
ought to suggest an examination of the joint of the lower jaw. 

The eruption of herpes blisters in the ear and its surroundings is 
noticed in rare cases after pain lasted for several weeks due to real neu- 
ritis. In very rare cases a transitory paresis of the facial nerve and 
affection of the auditory nerve were noticed. 

Otalgia in both ears suggests some constitutional anomaly. 

The therapy of otalgia is self-evident if its cause is caries of a tooth, 
or angina, or some affection of the larynx. 

The local pain in the ear disappears in most cases with the removal 
of its cause. The other cases of otalgia may, like prosopalgia, be very 
refractory to the usual local and general antineuralgic therapy. A piece 
of cotton soaked in equal parts of oleum hyoscyami and chloroform in- 

258 



Motor Neurosis of the Middle Ear. 259 

serted into the ear, and the same fluid rubbed into the surrounding skin, 
may be used as a palliative treatment. 

Motor Neurosis of the Middle Ear. 

Endotic noises, i. e., noises audible also to others, may be produced 
by clonic spasms of the muscles in the middle ear. 

A clicking noise which is not synchronous with the pulse, but re- 
peats itself ioo times a minute and more, can sometimes be heard at a 
considerable distance. It is produced by the separation of the lateral 
wall of the cartilaginous tube from the medial wall through clonic spasms 
of the tensor tympani and levator veli muscles. A simultaneous rythmi- 
cal raising of the soft palate is often visible. This noise is most fre- 
quently observed in children and hysterical women. 

Low rumbling noises occur in the ear when there is a spasm of the 
tensor tympani or stapedius muscle. The same noise is noticed physi- 
ologically in yawning when at the same time hard hearing of consider- 
able degree can be observed, and in forced voluntary contraction of the 
M. orbicularis palpebrarum, caused by a simultaneous contraction of the 
M. stapedius. 

According to some authors an extraordinarily acute hearing for 
sounds of low pitch is observed in paralysis of the facial nerve extending 
to the M. stapedius. I examined a number of fresh cases of paralysis of 
the facial nerve by means of a tuning fork of as low a pitch as 12 v. d. 
They showed no deviations from the normal, and no difference between 
the healthy and the affected ear. 

I made a number of valuable observations about spasms of the M. 
tensor tympani on a professor of clinical medicine, who was mentally 
overworked. He suffered at the same time from a fluttering noise which 
he was able to produce voluntarily. I saw at this moment a simultaneous 
change of the reflexes of the tympanic membrane. He was able to con- 
tinue the contraction of the tensor tympani muscle for any length of 
time, giving me a chance to make an accurate hearing test of the ear, 
which was normal in every other respect. The hearing distance for 
whisper did not materially change, but the lowest audible sounds were 
raised from C2 (16 v. d.) to Bi and E. Tuning fork A on the vertex was 
heard 18 seconds longer. Bone conduction and Rhine's test by means of 
tuning fork a', which is two octaves higher than A, were not influenced. 

In this case I could therefore experimentally test the physiological 
influence of an increase in tension in the sound-conducting apparatus. 
The insertion of the tensor muscle is situated very favorably for an ex- 
tension of the axis ligament on the neck of the hammer, but relatively 
unfavorably for a high tension of the tympanic membrane. This obser- 
vation shows that the contraction of the tensor muscle influences the 
hearing of all sounds of lower pitch than a' in the well known manner, 
namely: hearing of about the two lowest octaves in the air conduction 
is completely effaced. 



260 New Growths in the Middle Ear. 

Other objectively audible noises may be produced in the ear by air 
entering through the tube and passing through the secretions in the tym- 
panic cavity, or by passing through a narrow perforation in the mem- 
brane. Endotic noises may be caused in rare cases by aneurysms in the 
vicinity of the ear. 

The therapy of clonic spasms of the muscles in the middle ear can 
only be general roborant. 

New Growths and Formation of Cavities in the 
Middle Ear. 

We discussed the most frequent new formations in the spaces of the 
middle ear, namely granulations and polyps, together with the different 
forms of otitis media purulenta which cause them. 

Malignant tumors of these spaces are very rare. Kuhn for example 
says that of 128 carcinomata seen at the post-mortem table in the patho- 
logic institution in Berne "not a single one was located either in the ear 
or nose." 

In my own statistics I can count only 3 cases of sarcoma and 1 of 
carcinoma of the middle ear. In other words there is one case of malig- 
nant tumor of the middle ear to 5,000 ear patients. 

Sarcoma was observed most frequently in small children, carcinoma 
in the very old. 

Sarcoma which develops in the mastoid process, as in the cases 
which I observed, may present the clinical picture of a subperiostal ab- 
scess. It may raise the auricle in the same manner and may even show 
false fluctuation on account of its softness. 

The case of epithelial carcinoma of the mastoid process which I op- 
erated, presented a clinical picture similar to a penetration of pus into the 
neck. A hard swelling was found belozv the mastoid process. It was 
however produced by lymph glands involved in the new formation. 

The whole mastoid process, after a thick layer of bone was removed, 
was filled with solid, pale masses of granulation showing fine whitish 
spots which the sharp spoon cut exceptionally easily. The microscope 
revealed these spots to be perls of cancroid in a characteristic epithelial 
carcinoma. 

The development of a carcinoma in the middle ear is sometimes pre- 
ceded by a chronic suppuration of the middle ear for many years. 

The patients usually seek treatment at a comparatively late stage of 
the disease when an operation does not afford any advantages, but only 
hastens the fatal issue by opening avenues for the development of a 
meningitis. An operation must by all means be avoided when facial 
paralysis and deafness indicate the formidable extension of the neoplasm. 

Kuhn reports a case of prolapse of 'the cerebellum which formed 
after several sequesters had been removed from behind the ear. The 
operator taking it for a tumor removed it. The consequence was a fatal 
meningitis. 



New Grozvths in the Middle Ear. 261 

There was a time when we were not able to directly observe through 
the ear speculum the frequent extension of epidermis over the walls of 
the spaces of the middle ear, which, as we saw in the discussion of 
chronic suppuration of the middle ear, furnishes the soil for the develop- 
ment of cholesteatoma. At that time the pathological anatomists could 
not fail to notice the concentric gatherings of epidermis in the tem- 
poral bone on account of the large size which they sometimes acquire 
and the frequency of their occurrence. They described them as pearl 
tumor (Cruveiller), as cholesteatoma or margaritoma (Virchow) . They 
were, and could be considered as nothing else but true heterotopic tumors 
at that time. The otologist, by clinical observation of chronic suppura- 
tions of the middle ear, together with the findings at the numerous radi- 
cal operations and at the post-mortem table first showed that epidermisa- 
tion of the spaces of the middle ear is a process of healing in otitis media 
purulenta chronica with marginal perforations of the tympanic mem- 
brane, and that the onionpeel-like gatherings are the consequence of 
their retention in cavities with insufficiently large openings. It is not 
surprising that these masses of epidermis may, by pressure atrophy of 
the bone, extend to all parts of the temporal bone or beyond it in the 
course of many years. 

This is no doubt a very simple and very satisfactory explanation of 
the development of cholesteatoma in the temporal bone. There are, how- 
ever, in spite of it, not only a number of pathologists devoid of all clinical 
experience, but also otologists who even to this day do not want to give 
up the idea that at least the larger gatherings of epidermis in the tem- 
poral bone on account of the large size which they sometimes acquire 
of particles of epidermis. 

The number of cases reported in literature of cholesteatoma, which 
apparently do not coincide with the usual mode of development, in other 
words, which seemed to originate independently from suppuration of the 
middle ear, is so small compared to the many thousands with a clear 
pathogenesis that we are justified in considering the possibility that the 
process of suppuration in them was overlooked. This supposition is 
supported by the fact that in exceptional cases the defect in the tympanic 
membrane may close over a cholesteatoma. 1 These questionable cases 
of "primary" cholesteatoma can practically not be considered in making 
a diagnosis. 

The relative size of the gathering of cholesteatoma can not be a dif- 
ferential diagnostic criterion, nevertheless it appeared necessary to say 
one more word about these large formations because they lead to the 
formation of cavities, a change in the temporal bone which requires some 
consideration. 

Pressure atrophy produced by the masses becomes the most fre- 
quently visible on the posterior superior bony wall of the meatus. The 

l Otitis media purulenta, etc. Beitrage z. Aetiol. d. Cholesteatoma Inaug. Diss. Munich, 1895, 
by Karl Hugel, page 86. 



262 



Formation of Cavities in the Middle Ear. 



masses can often be evacuated if the defect in the bone has become large 
enough (compare fig. 75). There is a comparatively great number of 
cases which show at the examination a large cavity more or less empty, 
that is freely accessible through a defect in the roof of the bony meatus. 
It sometimes contains some secretion and remnants of cholesteatoma, 
which are usually very fetid. The removal of these contents is easily 
accomplished by direct injection through the antrum tube. The pressure 
of the injection must, however, increase gradually and not become too 
high, as the dura is often laid bare or the labyrinth is open at some part 
of these large cavities. The splitting of a bridge of skin in the meatus 
which has no bony support (compare page 207) is sometimes necessary 
in order to evacuate the masses. Large cavities in the bone are some- 
times found absolutely empty and dry. 

It will be of interest to hear something about the real size of the cav- 
ities formed in this manner in the temporal bone. 





a b 

Fig. 74. 

Cholesteatomatous masses removed through a gap in the bony meatus. 
o convex surface presenting a cast of the cavity, b concave surface directed towards the meatus. 



Years ago I described a method for measuring the contents. It con- 
sists in that we fill the cavity with some fluid which we measure after 
evacuation in a graduated glass. The contents of the cavity measured 
in this manner may appear smaller than it is in reality as the air is 
sometimes not entirely removed from some recesses, or thick scales of 
epidermis are still retained, but the result of such measurements can 
never transgress the real size of the cavity. 

I induced Hummel to measure in this manner the contents of the ex- 
ternal meatus of a large number of adults. He found 1.0 to 1.3 cubic 
centimeters. We obtain the dimensions of the cavity by subtracting the 
contents of the meatus from the contents of the whole cavity. Hummel 
found cavities in the living measuring as much as three cubic centimeters. 

A short while ago I measured a cavity on the living which showed 
no less than 8 cubic centimeters without the meatus. We obtained a 
rarely beautiful picture by transillumination upon inserting a small elec- 



Formation of Cavities in the Middle Ear. 263 

trie lamp (Valentin's salpingoscope) into the cavity through the large 
defect in the meatus. The limits of the cavity extended upward and 
backward all around the upper and rear insertion of the auricle. The 
presence of the large cavity could also be demonstrated by means of a 
small metal hammer, which in percussion produced a very sonorous 
sound over the whole extent of the underlying cavity. A very interest- 
ing phenomenon was produced by closing the meatus with the finger. 
The pitch of the sound of percussion became about one octave lower to 
the musical ear. The cavity showed therefore the same acoustic phenome- 
non as an open and a covered whistle. Another experiment demonstrated 
that either the dura or the carotid artery was to a large extent exposed 
in the wall of the cavity. By filling the cavity with some fluid up to the 
level of the entrance of the meatus, while the head was in a horizontal 
position, the fluid showed extensive pulsating movements. 



LECTURE XXVIIL 

Diseases of the Inner Ear. 
General Part. 

Gentlemen: — Nearly 11 per cent of all diseases of the ear that we 
observe are confined to the inner ear (according to Bezold's statistics). 
Of these patients 14.3 per cent=i/7 are children, 85.7=6/7 are adults. 
One ear was affected in 41.9 per cent, both in 58.1 per cent. 

We find here in the first place the cases of deaf-mutism ; furthermore 
the cases of permanent absolute deafness, and those where deafness is 
combined with defective speech. We shall see in speaking about infec- 
tious diseases of children, which so often endanger the inner ear, why 
the serious cases of diseases of the labyrinth occur so often in children. 
These diseases are most important in the etiology of affections of the 
labyrinth and the acoustic nerve during this period of life. In adults 
there are other causes for the numerous cases of diseases of the inner 
ear. They are changes due to old age, to trauma, to professional or oc- 
casional influences of very strong sounds and their consequences, to lues, 
to intoxications, and finally to the last stages of otosclerosis (spongifying 
of the capsula of the labyrinth). In a previous chapter we spoke about 
the direct progress of suppuration of the middle ear to the labyrinth. 
Tumors of the auditory nerve occur as often in children as they do in 
adults. 

The pathologic anatomy of the labyrinth is not sufficiently in- 
vestigated in all its details to give us a clear insight everywhere. Histo- 
logical investigation of the cavities of the labyrinth and their delicate 
membranous contents enclosed in the hardest parts of the temporal bone 
was made possible only since imbedding in celloidin and the microtome 
were introduced into the microscopical technic. Nevertheless we know 
today a large number of important clinically well characterized pictures, 
their mode of development, their course, and their final result. This is 
especially true of inflammations of the spaces of the labyrinth in cerebro- 
spinal meningitis, in syphilis, in suppurations of the middle ear and in 

264 



Diseases of the Inner Ear. 265 

trauma, as also in toxic poly-neuritis of the auditory nerve and after in- 
fectious diseases. 

In the first stages of suppurative labyrinthitis we find swelling and 
hyperemia of the endostium which is the layer of connective tissue lining 
the bony walls of the cavities. The membranous labyrinth becomes in- 
volved a little later on. In very serious cases we see necrosis of the en- 
dostium, of the bony contents of the cochlea together with the ductus 
cochlearis, and also of the membranous semicircular canals, and even of 
the bony walls after they have lost their endostium. The suppuration 
may lead to absorbtion of bone and formation of sequesters. Abundant 
granulation tissue develops which fills the cavities of the labyrinth en- 
tirely or partially, changing later on to fine connective tissue or osteoid 
substance, and finally into bone. The modiolus cochleae together with 
its gangliar masses is usually destroyed, the auditory nerve becomes in- 
flamed, thereby starting the process of degeneration of its main trunk. 

We find macroscopically during the acute stage of neuritis of the 
auditory nerve an increase of volume and a hyperemia of the nerve. 
Microscopically we see swelling of the nerve fibres and infiltration of the 
interstitial tissue with round-cells. The nerve fibres atrophy later on, 
while at the same time the interstitial connective tissue increases in pro- 
portion. Such a nerve may appear macroscopically unchanged except 
for the increase of volume. Furthermore simple processes of degenera- 
tion of the nerve elements are observed in the auditory nerve without 
proliferation of connective tissue. 

In post-mortems of deaf-mutes we find, in the minority of cases, a 
macroscopically visible atrophy of the auditory nerve. The spaces of the 
labyrinth are usually filled entirely or partially with connective tissue, or 
bone, in cases which became deaf by acquiring a suppurative labyrinthitis. 
A more or less extended destruction of the membranous parts of the 
cochlea is always found. The macroscopical examination of congenital 
deaf-mutes usually produces few positive results, except in those cases 
of enlargement of the aquaeduct and of the membranous apex of the 
cochlea which show only a partial development of the bony walls of those 
canals. The scala vestibuli and the scala tympani in those cases are di- 
vided by the lamina spiralis only in the 1^2 lower whorls, and the apex 
of the cochlea forms one large common bone cavity which contains the 
ectatic upper part of the ductus cochlearis. The congenital absence of 
both labyrinths was so far observed in one single case. Histological 
changes of the membranous cochlea were found in all cases -of congeni- 
tal deaf-mutism which were microscopically examined by men who know 
how to use all modern adjuvants. They consisted of a more or less ex- 
tended degeneration of the epithelium of some parts of the endolymphatic 
space, especially of the papilla basilaris (Corti's organ) ; changes of the 
aperture of the membranous ductus cochlearis are frequently observed, 
while the membranous and nervous parts of the vestibulum usually differ 
only very slightly from the normal, or not at all. 



266 Clinical Picture of Diseases of the Inner Ear. 

We have very little accurate knowledge about the changes in the 
senile form of labyrinthine deafness, in cases of one-sided deafness oc- 
curring with Meniere's symptoms without a concommitant infectious dis- 
ease, and in hard hearing and deafness occurring in cretins. ■ 

The clinical picture of diseases of the inner ear is primarily charac- 
terized by the kind of interference to which hearing is subjected. The 
defect of function in exclusive diseases of the external and middle ear is 
produced by some disturbance of equilibrium in the sound-conducting 
apparatus, either by overbalancing one part or another, or by fixation, or 
by partial defect of this apparatus. It can be shown to be a simple in- 
terference with conduction by means of functional tests. All functional 
peculiarities which are characteristic for the presence of an interference 
with conduction of sound are absent in pure diseases of the inner ear. 

I explained to you that in hearing by air conduction the lower end 
of the sound scale always suffers in diseases of the middle ear. A com- 
plete loss of hearing for the lowest sounds is always present. The more 
intense hard hearing becomes the higher this loss of hearing mounts in 
the sound scale. Hearing may extend, though weakened, to the lower 
end of the sound scale only in acute processes of exudation. These 
processes however offer no difficulty to diagnosis by virtue of their ob- 
jective findings. A more or less extensive loss of hearing for the lowest 
sounds is always present, even in the slightest defects of hearing, in all 
other diseases of the middle ear. It is found especially in those cases of 
otosclerosis which on account of the negative findings of the tympanic 
membrane are easily mistaken for diseases of the inner ear. 

A disease of the middle ear as the cause of hard hearing must be 
excluded in all patients who hear the lowest tuning fork C 2 (16 v. d.) by 
air conduction. No other possibility is left in such cases than to locate 
the disease beyond the middle ear ; that is in the inner ear. 

Hearing of the lowest part of the sound scale in the majority of 
cases of "nervous deafness," as they are called, is absolutely intact. They 
are characterized as diseases of the inner ear by their ability to hear 
16 v. d. and less by air conduction. Hearing of the lowest part of the 
sound scale is even preserved in patients who have great difficulty in 
understanding speech, and even in some deaf-mutes with remnants of 
hearing. 

There is a comparatively small number of cases of diseases of the 
inner ear whose hearing of the lowest sounds is interfered with or ef- 
faced. They are the diseases of that part of Corti's organ which per- 
ceives the low sounds and is located in the cupula of the cochlea, accord- 
ing to v. Helmholtz. 

Another peculiarity of diseases of the middle ear helps us to make a 
differential diagnosis in those cases. It is never absent even in acute 
exudations in the middle ear, namely, an increase and prolongation of 
hearing of low sounds by bone conduction. 



Clinical Picture of Diseases of the Inner Ear. 267 

A disease of the middle ear either alone or combined with an affec- 
tion of the inner ear is present in all cases which hear sounds inaudible 
to them by air conduction, longer than normal, when the tuning fork is 
placed on the vertex. All pure diseases of the apparatus of perception 
interfere equally much with hearing of sounds of any pitch by air and 
bone conduction. Daily experience confirms this supposition to such an 
extent that we always find a small shortening of bone conduction in cases 
which hear speech badly, but hear well the lowest part of the sound 
scale. 

A gradual increase of hard hearing by air conduction towards the 
lower end of the sound scale is always found in pure diseases of the 
sound-conducting apparatus. Diseases of the inner ear, on the other 
hand, may involve parts of different extension in any part of the sound 
scale. We may therefore find some parts of the sound scale that are 
not heard as well as others above and below, or hearing may be entirely 
destroyed for some parts ; that is we find islands or gaps of hearing. 

The cause of total deafness must always be found in the inner ear. 
A remnant of hearing at least in the upper part of the sound scale is al- 
ways found in pure diseases of the middle ear. 

Air conduction and bone conduction are equally concerned in pure 
diseases of the apparatus of the auditory nerve. Their relation to each 
other therefore does not change, i. e., Rhine's test is positive nearly or 
entirely the same as in the normal ear. 

The differential diagnosis in nervous deafness of one ear only is 
more difficult. 

Weber's test might help us in these cases, but just here the state- 
ments of the patients are too unreliable to be used for differential diag- 
nosis. 

The duration of bone conduction (Schwabach's test on the vertex) 
may be normal, or little longer than normal, for low sounds, especially in 
cases where there are residues in the sound conducting apparatus. 
Rhine's test may also be negative if bone conduction for low sounds is 
prolonged, especially if there is a high degree of deafness, because the 
tuning fork on the mastoid process of the diseased ear is heard in the 
other ear which is nearly or entirely normal. The functional picture of 
the diseased ear is therefore covered to some extent by that of the nor- 
mal or better ear. A diagnosis of nervous deafness of one ear is, never- 
theless, usually possible. 

The differentia] diagnosis is most difficult in cases where the middle 
and inner ear are diseased at the same time. An acute disease of the 
middle ear which develops at the same time as a disease of the inner ear 
is recognized from visible changes on the tympanic membrane, and by 
means of ausultation. The simultaneous disease of the inner ear is diag- 
nosed from the disproportionate decrease of hearing which is not of 
equal intensity in all parts of the sound scale. There are for example 



268 Clinical Picture of Diseases of the Inner Ear. 

numbers, other than those in diseases of the middle-ear, which are not 
understood so well, especially such as contain sibilants. Hearing of a 
considerable part at the upper end of the sound scale, tested by the 
Gait on whistle, may be lost, or circumscribed gaps may be found in this 
region. 

An accurate diagnosis is especially difficult in diseases of the inner 
ear, combined with chronic diseases of the sound conducting apparatus 
which shows no changes at the tympanic membrane or in auscultation. 
Even there we are usually able to recognize and differentiate both dis- 
eases with reasonable accuracy. The final stages of otosclerosis are 
mainly concerned here. They often show a considerable shortening, or 
even complete deafness, for tuning fork a' from the vertex, and the loss 
of hearing of a large part at the upper limit, or gaps in the region of Gal- 
ton's whistle ; but at the same time there is a considerable prolongation 
of bone conduction for A far beyond the normal, which indicates the 
simultaneous presence of a fixation of the stapes. 

Subjective noises alone are no safe indicators of the seat of the dis- 
ease as they are at least as frequent in affections of the middle ear (in 
sclerosis they are even more frequent) than in exclusive diseases of the 
nervous apparatus. Their great variety is often peculiar to nervous 
deafness and causes it to be very trying to the patient. The hearing of 
words or melodies must however always be considered as illusion or 
hallucination, and must be attributed to the brain center. 

There are .other functional abnormities observed in affections of the 
labyrinth, dizziness, nystagmus, interferences with equilibrium, which 
can be objectively proved. They occur in diseases of the vestibulum and 
semicircular canals, which may exist either alone or together with dis- 
eases of other parts of the labyrinth. 

There is a large number of patients with nervous deafness who 
never suffered from any of these symptoms. We have to locate their ill- 
ness in the cochlea exclusively, if there is no reason for locating it al- 
together beyond the labyrinth. We cannot be in doubt as to the origin 
of the disease being in the labyrinth in cases which show a sudden onset 
of disturbances of equilibrium together with nystagmus, and where these 
disturbances set in with such violence that the patients fall down and 
vomit. Disturbances of equilibrium of a minor degree are often ob- 
served in diseases of the sound conducting apparatus especially in oto- 
sclerosis. 

Some statistical facts must be mentioned. The majority of cases of 
nervous deafness are men (according to BezoloVs statistics, 77 to 78 per 
cent), while more than half of the patients suffering from sclerosis are 
women. Nervous deafness is mostly a disease of old age, while sclerosis 
develops rather in middle age and often during, or soon after, the time 
of puberty. 

You will recognize, gentlemen, that our diagnosis in this region 



Clinical Picture of Diseases of the Inner Ear. 269 

hidden to visual examination does not rest on such an unsafe basis as is 
often pretended, if you consider how often etiology from the beginning 
directs our attention to the inner ear in revealing such points as sudden 
appearance of deafness with or without a preceding trauma, detonations, 
simultaneous or preceding general diseases like lues, meningitis, etc. 

The functional examinations alone can however not reveal whether 
the disease is located in the labyrinth, or in the auditory nerve, or in the 
brain center. Well circumscribed defects in the sound scale, gaps, 
islands, etc., can undoubtedly only originate in the cochlea. 

A disease of only one side of the first and second temporal convolu- 
tions containing the cortical center of hearing, and of the corresponding 
parts of the crus cerebri does not cause complete deafness of the other 
ear because of only partial decussation of the auditory nerves. A dis- 
ease of the upper convolution of the left temporal lobe leads to amnestic 
aphasia (inability to find certain words), and very rarely to sensory deaf- 
ness (psychic or word deafness) where speech is heard but not under- 
stood. 

We have to discuss the disturbances of equilibrium more carefully. 

The feeling of dizziness is not a regular, but a frequent, symptom of 
disease of the labyrinth. It is often the most important symptom in acute 
labyrinthitis and increases w T ith each change of position. Vomiting may 
occur during the hight of an attack of dizziness. The patients are 
sometimes forced to lie in bed for weeks without moving. This symp- 
tom in children is often not recognized by the relatives and is taken for 
simple weakness. 

Dizziness occurs later on only in the form of attacks especially after 
quick movements of the body and eyes. Walking sometimes becomes 
unsafe, the patient, especially if his eyes are closed, has the tendency to 
deviate or to fall most often towards the side of the diseased ear. 

Dizziness originating from the ear can be differentiated from dizzi- 
ness produced by paralysis of the muscles of the eyes in that the latter 
disappears when the eyes are closed, while the former does not, and from 
dizziness in spinal ataxia by the subjective feeling of dizziness which is 
present. Cerebellar ataxia causes on the whole the same symptoms as 
does vestibular ataxia. 

Sometimes there is not only a vague feeling of dizziness but a dis- 
tinct impression of movement, so that the surrounding objects seem to 
move rapidly over the field of vision in a horizontal direction (rarely 
vertical). In such cases corresponding nystagmus can be directly ob- 
served and can be produced, or increased if already present, by having the 
patient look towards the side of the good ear. These symptoms occur 
only when the vestibulum, or the semicircular canals, or the vestibular 
nerve in its central course, are irritated. The irritation may be increased 
by 5 to 10 quick rotations around a vertical axis in the direction of 
the sick ear. 



270 Clinical Picture of Diseases of the Inner Ear. 



The nystagmus reaction is very strong in this case. It is also pres- 
ent, but less strong, when the experiment is made to turn in the opposite 
direction, thereby irritating the healthy ear. The opposite to the healthy 
condition prevails, that is, the symptoms of irritation are absent, no diz- 
ziness and no nystagmus is produced in rotation of the body around a 
vertical axis when the stage of irritation in the affection of the labyrinth 
has passed, and the endings of the vestibular nerve in the labyrinth are 
completely destroyed. Walking, especially in children, remains straddling 
and helpless for a long time after this state is reached. 

The absence of nystagmus and dizziness indicates therefore the de- 
struction of the endings of the nerve in the vestibulum, in the semicircu- 
lar canals, or of the nervus vestibuli, as deafness is a criterion for de- 
struction of Corti's organ in the cochlea or of the nervus cochleae. 

The sum of labyrinth symptoms consisting of subjective noises, diz- 
ziness also in horizontal position combined with vomiting, nystagmus, 
and deafness are often called the complex of Meniere's Symptoms. 
They may be observed in all diseases which are apt to produce irritation 
of the vestibular nerve. There is no special Meniere's disease. Accord- 
ing to what Meniere reported about the single case upon which he based 
his clinical picture, it was a case of sporadic or epidemic cerebro-spinal 
meningitis. It is frequently complicated with labyrinthitis of both ears, 
and may lead to deafness and death, and yet at a superficial macroscopic 
post-mortem examination no pronounced meningeal symptoms are vis- 
ible, as happened in Meniere's case and the well known cases of Volto- 
lini. 

There is another very rare form of Meniere's complex of symptoms 
which shows no loss of hearing but certainly originates from the ear. 



LECTURE XXIX. 
Special Pathology and Therapy of the Inner Ear. 

Subjective Noises. 

Gentlemen : — The mildest form of affection of the inner ear is called 
tinnitus aurium in our statistics. They are cases of subjective noises 
which neither at the inspection nor at the functional examination show 
an involvment of the external or middle ear, nor any loss of hearing. 
Their occurrence is not very rare ; Bezold found it in 2.6 per cent of all 
ear patients. Some of them depend upon some general disease, as chloro- 
sis, anomalies of blood vessels, psychic excitement, weakness ; some are 
the consequences of frequent night vigils, etc. The character of the noise 
is very different; sometimes it is rumbling and low, like the noise of a 
moving railroad train, or like the street noise heard at a distance, or the 
humming of an insect, at other times it is of a high pitch and shrill like 
the chirping of a cricket, the noise of escaping steam, the clear ringing 
of bells and distinct musical sounds. The noise changes sometimes in 
the same patient. I observed some patients afflicted especially with 
noises of high pitch who in later years lost some of their previously nor- 
mal hearing power. An organic lesion of the auditory nerve had to be 
diagnosed, as hearing of a considerable piece at the upper end of the 
audible sound scale was lost, although the hearing distance for speech 
had decreased only slightly. 

Hearing of human voices and distinct words is due to hallucinations 
and psychical alterations, even if it is the only symptom for the time 
being. 

The treatment must consider principally the general organism ; 
harmful influences like overwork, excitement, etc., must be eliminated. 
Catheterisation may be tried as a local remedy. The prognosis is favor- 
able if after the first inflation the noise does not disappear for a few sec- 
onds only (as this may frequently occur also in organic lesions) but at 
least for some hours. In such cases the method must be continued till 
the noise stops entirely. Physical procedures like pressure by means of 

271 



272 Degenerative Processes in the Labyrinth. 

Siegle's funnel, or Delstanche's rarefactor, or massage, galvanisation, 
and other methods acting more or less by way of suggestion, usually 
have no result if the catheter fails. Quinine in small doses (0.2 a day), 
phenacetine 2x0.5 a day, antipyrine 3 to 4x0.3 a day may be tried in- 
ternally for several weeks without interruption. Valerian and bromides 
may act as palliatives. 

Degenerative Processes in the Labyrinth. Presbyacusis, 
Cretinism. Retinitis Pigmentosa. 

A certain decrease of the power of hearing is a regular senile phe- 
nomenon (presbyacusis). It is however not strictly peculiar to senility 
but may occur earlier, corresponding to a general law that senile degen- 
eration of any organ may take place in different individuals at different 
decades of life. Hereditary influences are evident in this regard. The 
beginning and the development of senile deafness frequently occur 
slowly and imperceptibly. Other disorders besides senile degeneration 
must be taken for granted when there is ringing and dizziness present. 

Senile deafness always concerns both ears. The functional tests 
show the clear picture of nervous deafness, modified to such an extent 
that hearing in the region of Galtons whistle is usually considerably re- 
duced. Deafness for the high sibilants s, z, sh, th, (j, g), occurs rela- 
tively early, rendering conversation for presbyacutic people more difficult, 
especially in the noise of general conversation at table. That old people 
are deaf to chirping of crickets is generally known. A defect of hear- 
ing at the lower end of the sound scale is rarely observed. According to 
anatomical findings it is due to calcification of the lig. annulare without a 
spongifying process taking place in the surrounding bone. 

Other histological changes, especially a high degree of arterioscle- 
rosis, could not be established in any part of the inner ear in senile deaf- 
ness. To determine this fact we examined microscopically a large num- 
ber of cases, whose functional tests we had made during life, and who 
had gradually developed deafness while preserving an intact middle ear 
(though becoming very deaf later on). Other authors however de- 
scribed histological changes in the cochlea which might possibly be con- 
sidered as senile changes. They consist of a decrease of the aperture 
(collapse) of the membranous ductus cochlearis and a flattening and 
even partial atrophy of its sensory epithelium. 

The prognosis and therapy are identical with that of senile changes 
in general. 

We find other chronic degenerative processes in the inner ear, with- 
out perceptible neuritis of the auditory nerves, in certain congenital pre- 
dispositions to disease. The cases of slow progressive deafness in 
cretinism and in retinitis pigmentosa must be mentioned here. 

Symptoms of irritation of the labyrinth seem to be absent in deaf- 
ness from cretinism, as also in deafness in connection with retinitis pig- 



Inflammatory Processes in the Labyrinth. 273 

mentosa. There are however distinct symptoms of vestibular defect in 
the stationary, as well as in the slowly progressive form of cretinic deaf- 
ness. They are evident in the walk and in the carriage of the patient as 
well as in the rotatory test, in as far as the normal reaction of nystagmus 
occurs only incompletely or not at all. In deafness in connection with 
retinitis pigmentosa there are similar pathological processes as in senile 
deafness, according to our histological examination of one of these cases. 
The results of examinations of the changes of the labyrinth in cretinism 
are not yet sufficiently numerous, and not uniform. 

It is possible that the therapy with thyroid gland may arrest the 
progress of cretinic deafness. We were however in no case able to pro- 
duce by it a real improvement of hearing. Apparently favorable results 
caused by the use of thyroid gland are due to the increase of intelligence 
and of the power of combination which allows these patients to find 
partly understood words and phrases by conjecture. 

We will also mention at this place several cases of deafness ob- 
served after ligation of the carotid artery. 

Inflammatory Processes in the Labyrinth. 

We have previously spoken about perforations of suppurations from 
the middle ear into the labyrinth. The cavities of the labyrinth may 
furthermore be seriously interfered with, in the first place by meningitis 
and syphilis. Then grouped according to the degree of danger for this 
part of the organ of hearing, follow scarlet fever, influenza and influ- 
enza-like diseases of the respiratory organs, typhoid fever, mumps, 
measles, osteomyelitis, smallpox, whooping cough. 

In the course of each one of the diseases named there are clinically 
observed cases of hard hearing, or deafness, which we have to attribute 
exclusively to the inner ear, according to the results of our functional 
tests. Each one furnishes a greater or smaller number of children for 
the deaf and dumb institutions. 

A peculiar position must be accorded leucemia, which is complicated 
in its pernicious course in more than 10 per cent of its cases with laby- 
rinthitis. It has however less practical than purely clinical interest on 
account of its almost unexceptionally fatal termination. Its course is 
sometimes chronic, sometimes apoplectiform, in the latter case it shows 
Meniere's symptoms. The histological results are hemorrhages in the 
semicircular canals and especially in the cochlea, with partial destruction 
of the membranous labyrinth, and also of the stem and branches of the 
auditory nerve ; furthermore there is lymphoid exudation in the cavities 
of the labyrinth and in the nerve. Connective tissue and bone may de- 
velop later on in the spaces of the labyrinth. 

1. Meningitis Cerebrospinalis. 

Labyrinthitis occurs on an average in 30 per cent of cases of 
cerebro-spinal meningitis. Of those who survive more than 10 per cent 

18 



274 Cerebrospinal Meningitis. 

remain hard of hearing or deaf. Not all epidemics are equally danger- 
ous to the organ of hearing. Children always seem to run the greatest 
risk, so much so that for several years after such an epidemic has in- 
vaded a country some deaf and dumb institutions are filled exclusively 
with inmates who lost their hearing by cerebro-spinal meningitis. This 
class of deaf-mutes even today represents half of all the deaf and dumb, 
although for decades this disease occurred in Europe only sporadically 
or in small epidemics. 

It is of greatest practical importance that the intensity of the clini- 
cal symptoms of meningitis is often so insignificant that they are in no 
proportion to the seriousness of the affection of the labyrinth. 

Complete deafness may be caused by very light abortive cases, but 
even they can not always be recognized as such on account of the absence 
of a simultaneous epidemic in the town, or of some serious illness in 
sisters or brothers or neighbors. The same incongruity exists sometimes 
between the clinical symptoms and the result of the post-mortem of the 
central organs, as the nature of the disease which terminates fatally in 
so short a time does not always become evident from those apparently in- 
significant pathologic anatomical changes. 

Inflammation of the labyrinth almost always involves both ears (ac- 
cording to Bezold in 91.8 per cent). It acts as a destructive process of 
the perilymphatic space, showing hyperemia, stasis, thrombosis and 
rupture of the small blood vessels, fibrinous infiltration and necrotic de- 
cay of the endostium. Suppuration, superficial necrosis of bone, neuritis 
of the auditorv nerve occur later on, as I told vou in the introduction to 
this chapter. 

An inflammation of the middle ear accompanies the meningitic 
labyrinthitis and the cerebro-spinal meningitis in more than half of the 
cases. It usually passes rapidly, runs a very mild course, and is there- 
fore hardly ever clinically observed, especially on account of the serious- 
ness of the other symptoms of the disease. Different epidemics seem, 
however, to vary considerably since some otologists find later on 
otorrhoea and visible material changes of the tympanic membrane in 5 
per cent, others in 10 per cent and more, of patients who became deaf 
from cerebro-spinal meningitis. An inflammation usually of both middle 
ears is a regular part of the picture during the first period of cerebro- 
spinal meningitis, as is shown by the results of post-mortems of cases 
which took a rapid course. It does not lead to perforation in the major- 
ity of cases, not even to clinically demonstrable inflammatory changes 
of the tympanic membrane. In rare cases otorrhoea precedes the onset 
of meningitis. In cases where a perforation of the membrane occurs it 
takes place as a rule later on, sometimes as late as the sixth week and 
later, after the onset of meningitis. Destructive processes in the bone 
are very exceptional in cerebro-spinal suppuration of the middle ear-. 
Such a combination of suppuration of the middle ear with labyrinthitis 
may be called panotitis. 



Cerebrospinal Meningitis. 275 



In literature there is one post-mortem report of the findings in the 
labyrinth of a patient who became only moderately hard of hearing from 
meningitis. The small changes found there are entirely confined to the 
perilymphatic space. In completely deaf patients a destruction of the 
region of the papilla acustica, together with a more or less extensive 
alteration of the endolymphatic space is always found after an inflamma- 
tion of the labyrinth has run its course. The endostium is always pro- 
liferated in some, or in all parts. The space of the labyrinth contains 
connective tissue and bone, or is entirely replaced by bone. In extreme 
cases no cavities can be found in the place of the labyrinth. The stapes, 
often subluxated from the vestibulum towards the tympanic cavity, is 
ancylosed and the membrane of the round window thickened from pro- 
liferation of connective tissue, or calcified. The aqueducts are closed 
by connective tissue or bone and the auditory nerve is partially or en- 
tirely atrophic. The semicircular canals are most often filled in this 
manner. The cochlea may appear normal to the naked eye. 

We understand very easily that meningitis epidemica fills the deaf 
mute institutions if we remember that the first year of life is the most 
susceptible to it, as 13 to 27% of all patients are of that age according to 
large statistics. 

The affection of the labyrinth becomes noticeable most frequently 
during the second or third week of meningitis, rarely earlier or later. 
Its course is usually progressive and rapid, exceptionally it has a chronic 
character with remissions, when it may take an unfavorable turn even 
after several months. Subjective noise and rapidly progressing loss of 
hearing are present from the beginning of the disease as far as the age 
of the patient and the general symptoms, especially the absence of clear 
consciousness, admit of an examination of the subjective and objective 
symptoms of the labyrinth. The difficulty of hearing is usually only 
noticed during the hight of the disease when both labyrinths are at- 
tacked. The most prominent symptoms are the manifestations of the 
feeling of dizziness: these patients are often extraordinarily "weak" 
for weeks and months after the meningitis has run its course, i. e., they 
cannot stand up, they cannot sit down, but try to remain in bed, flat on 
their back for all this time. Older children forget how to walk, and 
when they learn it again, their gait for years remains unsteady and stag- 
gering. A peculiar inclination to stumble and fall is usually sponta- 
neously mentioned by the parents in giving the history of such children. 

The normal dizziness and nystagmus can usually not be produced 
by the experiment of rotation in most people who became deaf after 
meningitis had run its course. This allows the conclusion that the de- 
struction extended to the. vestibulum and semicircular canals. 

The diagnosis is often difficult or impossible in the beginning, 
especially in light sporadic cases, and when it concerns children during 
their first year of life. It is often made after the disease has run its 



276 Syphilis of the Labyrinth. 

course, a fact which may be of disagreeable consequences to the general 
practitioner. You will be led to think of the possibility, or the proba- 
bility, of a meningitic labyrinthitis if a small child, after a very slight 
not clearly pronounced meningitic attack, is particularly motionless, 
while you can not detect any abnormal subjective or objective symptoms, 
or if the child can not sit or stand when the nurse tries to force it to do 
so, while the child can move the extremities freely and does not indicate 
any pain. 

Hearing tests are rarely possible, even in adults, during the hight 
of the disease, but the increasing lack of perception in calling the name 
of the patient soon becomes evident. Complaints of subjective noises and 
nystagmus are frequent in the beginning. Nystagmus, feeling of dizzi- 
ness, and retching may also be due to the main disease. You must be 
very careful in your prognosis if a patient suffering from meningitis 
becomes hard of hearing, and you discover in him a suppuration of the 
middle ear which might or might not be the cause of the hard hearing. 
On the other hand it is evident that not every meningitis which occurs 
together with a suppuration of the middle ear and labyrinth, is induced 
from the ear and can therefore not always be called an "otitic meningi- 
tis." The possibility of a genuine meningitis with participation of the 
middle ear must, especially in children, not be forgotten in cases where 
we have to decide whether or not to operate in an apparent "otitic 
meningitis." 

Therapy seems to be powerless against meningitic labyrinthitis. 

2. Syphilis of the Labyrinth. 

Syphilis of the labyrinth occurs as a hereditary, and as an acquired 
disease. 

a. Hereditary lues of the labyrinth is mainly a disease of child- 
hood. It begins most frequently at the end of the first, rarely at the 
end of the second, decade. We observed it as a great exception in a 
woman of 25 who became deaf during childbed, showing the character- 
istic clinical picture in anamnesis, and anomalies of the eyes and ears. 
In another case which was equally clear, presenting Hutchinson's triad, 
we saw deafness develop rapidly in the 49th year of life. Deafness al- 
ways occurs some time after keratitis diffusa. The characteristic 
deformity of the teeth described by Hutchinson is not present in all 
cases. 

The frequency of occurrence of luetic labyrinthitis is best illus- 
trated by the fact that in the etiology of deaf -mutism, hereditary lues 
takes first rank after meningitis and suppuration of the middle ear, ac- 
cording to Bezold's statistics. Still the statement of several authors that 
one tenth to one third of all hereditary syphilitic children suffered from 
some disease of the organ of hearing is wrong, and much too high. 
Methodical investigations of the conditions of a number of unquestion- 



Syphilis of the Labyrinth. 277 

ably hereditary luetic children showed different instances where not one 
such child out of 40 to 50 was extraordinarily hard of hearing. There 
is a peculiar fact that the majority of the children are female, while the 
male sex predominates in all other diseases of the organ of hearing in 
children. 

Our diagnosis is based upon the presence of keratitis diffusa which 
had either lasted for a long time or had already healed, less frequently 
upon iritis or the characteristic choreoiditic changes of the fundus of 
the eye; furthermore upon the malformation of the upper incisors of the 
second dentition, upon ozena, gummata, loss of substance, scars in the 
fauces and other luetic symptoms of the patient and his family, upon 
several premature births in his mother, death of sisters and brothers 
soon after birth, etc. Changes in the tympanic membrane indicating 
prolonged occlusion of the tubes are frequently found. 

Inunctions of blue ointment, which were given in about half the 
cases on account of the preceding keratitis, do not protect the patient 
against a later occurrence of hereditary luetic labyrinthitis. 

A high degree of hard hearing almost always sets in in both ears, 
and rather suddenly. The disease of the ear may begin with dizziness 
and ringing. The latter sometimes remains, but either or both of these 
symptoms may be absent. The disease leads usually to deafness for 
speech, and deaf-mutism if it occurs in early childhood. 

The functional tests by means of the tuning forks reveal the symp- 
toms which are characteristic for disease of the labyrinth. Hard hear- 
ing extends over the whole sound scale, the upper end of the scale is not 
more interfered with than the lower. Sometimes the contrary appears 
to be the rule, according to our experience. Gaps of hearing are ob- 
served in some cases. Hearing of the ends of the scale becomes gradu- 
ally more effaced later on until only an island of hearing is left, which 
by and by also disappears. The progress of deafness may become sta- 
tionary at any stage. We therefore find deafness in one ear, combined 
with a smaller or larger degree of hard hearing in the other ear, in the 
same patient. Remnants of hearing which remained stationary for many 
years may gradually decrease later on. 

The prognosis as to restitution of hearing is very bad. 

The therapy seems to be powerless in arresting the progress of the 
process, even though temporary improvements were frequently observed 
during the treatment by inunction. At all events not a mo- 
ment must be lost in expectation or with remedies of doubtful value, 
whenever the diagnosis of a luectic disease of the labyrinth is made. 
Iodide of potassium may be tried in the very first stage, it is, however, 
worthless and even contraindicated later on. A result can only be ex- 
pected of the treatment by inunction which may be combined internally 
with Zittmann's decoction. This treatment must be given in a hospital 
by well trained nurses, and must be repeated several times at not too 
large intervals. 



278 Scarlet Fever, Measles and Diphtheria. 

b. In acquired lues the labyrinth is usually involved during the 
tertiary, rarely during the secondary stage. In the latter case it is sometimes 
accompanied by slight inflammation of the middle ear, and by symptoms 
of retraction of the tympanic membrane. Hard hearing here also de- 
velops rapidly, rarely slowly or remittently. Dizziness and subjective 
noises are observed less frequently than in the hereditary form of lues. 
Another difference between acquired and hereditary lues consists in the 
fact that women are much more rarely attacked by acquired lues of the 
inner ear than men, and that the disease in adults often remains con- 
fined to one ear. It must however be left to future investigations to de- 
cide in how far forms of pure polyneuritic character may act here, and 
whether or not symptomatology will ever permit a differential diagnosis 
in this direction. 

The therapy seems to show a difference between acquired and 
herditary lues in that a combination of mercury with the medication of 
iodides seems sometimes to give better results than either of the two 
alone. 

The prognosis is much better in acquired than in hereditary syphilis 
of the labyrinth. A complete recovery may occur even in very hard 
hearing patients, if treatment is applied early and energetically enough. 

Post-mortems show that the process in the labyrinth in lues, as in 
meningitic deafness, terminates in new formation of connective tissue 
and bone in all spaces of the labyrinth. Otitis interna luetica never 
leads to meningitis. Swelling and formation of lymphomata in the 
nerve substance of the branches of the auditory nerve were found in ac- 
quired lues. A number of reports of post-mortems of temporal bones 
belonging to persons who had hereditary syphilis show a destruction of 
the oval window and the labyrinth, caused by suppurations of the middle 
ear. These changes were most probably caused by tubercular processes. 

3. Scarlet Fever, Measles and Diphtheria. 

Clinical and anatomical examinations have shown that labyrinthitis 
in scarlet fever is caused most frequently by a perforation of the suppu- 
ration of the middle ear through the windows of the labyrinth (panoti- 
tis). This chapter has been discussed before. There is, however, a 
minority of cases where suddenly all symptoms of labyrinthitis with 
very hard hearing or deafness develop, without inflammation in the 
middle ear or perforation of the tympanic membrane or of the windows. 
Some of these cases are explained by a meningitic disease of the laby- 
rinth. Future pathologic anatomical investigations must, however, 
reveal in how far pure polyneuritic processes are found in similar cases 
of sudden development of deafness. 

Measles is sometimes the cause of labyrinthitis, but not by far as 
frequently as scarlet fever. We must make a distinction here also be- 
tween a form which propagated from the middle ear, and another, prob- 
ably of meningitic origin, occurring together with an intact middle ear. 



Mumps. Other Infectious Diseases. New Formations. 279 

Genuine diphtheria is not very dangerous to the organ of hearing, 
neither to the middle ear nor to the labyrinth. Nearly all cases of seri- 
ous deafness attributed to diphtheria may be ascribed to diphtheria after 
scarlet fever, or rather directly to scarlet fever itself, without fear of 
making a mistake. 

» 4. Mumps. 

The affection of one or both organs of hearing in parotitis epidem- 
ica is a rare and interesting disease. It is most often confined to one ear 
only. It occurs usually towards the end of the disease, and leads rap- 
idly to complete deafness of the affected ear. Violent attacks of dizzi- 
ness with vomiting accompany the disease in some cases, in others there 
is noise in the ear. Both symptoms may be absent. I have observed the 
same disease after an inflammation of the submaxillary glands, but only 
as a great exception. Complete deafness for speech is always present, 
but remnants of hearing may be discovered in some cases by means of 
the sound scale. 

The anatomical basis for deafness in mumps has not been suffi- 
ciently investigated. 

5. Other Infectious Diseases. 

Serious labyrinthitis resulting in deafness may occur in the course 
of influenza, and influenza-like affections of the respiratory organs, as 
also during pneumonia, typhoid fever, smallpox, and whooping cough. 
The middle ear, or a suppuration in its spaces, does not take any part 
whatsoever. There are so far no post-mortem results which reveal 
whether the labyrinth alone is diseased in these cases, or whether a post 
infectious neuritis is the cause of the disease. We are more accurately 
informed as to deafness in osteomyelitis and in leukaemia, which latter 
so far has been counted among constitutional diseases. In these two 
diseases we know the pathologic anatomical condition, although they are 
rare occurrences. Both organs of hearing are usually attacked. In 
osteomyelitic deafness we sometimes find considerable remnants of 
hearing for speech and the sound scale. Besides the leukaemic and 
typhoid labyrinthitis an independent leukaemic and typhoid neuritis, or 
polyneuritis, is observed. 

New Formations in the Labyrinth. 

New formations do not seem to occur primarily in the labyrinth. 
Two small neuromata accidentally were found in the vestibulum of two 
deaf-mutes. They are analogous to neuroma after amputations 
(Schwartze A. f. O. vol. V. page 297 and Schwabach Z. f. O. Vol. 
XLVIII page 303). Tumors of the auditory nerve are not very rare 
and will be discussed later on. Secondary new formations as a rule 
penetrate into the labyrinth from the middle ear, or more rarely through 



280 New Formations in the Labyrinth. 

the porus acusticus from the interior of the skull. We shall speak about 
the latter together with the affections of the nerve. Belonging to the 
first class we find the sarcomata in children, furthermore carcinomata 
which develop in the middle ear of young people in the form of basal 
cell carcinoma, and the flatcell carcinoma of old people, which arises 
from the external ear, or from a metaplasia of the lining of the middle 
ear. 

Tuberculosis of the inner ear is relatively not so rare. It occurs 
in children who have usually no affections of the lungs, or appear not to 
have any, and begins with the symptoms of a common acute, or sub- 
acute suppuration of the middle ear, often very rapidly attacking the 
facial nerve and the inner ear. We observe this disease more rarely in 
adults. A destructive tuberculosis of the middle ear and labyrinth oc- 
curs there more frequently during the far progressed stages of consump- 
tion. 

The clinical picture of these two forms of diseases of the middle 
ear was described under the heading of otitis media purulenta phthisica. 



LECTURE XXX. 

Affections of the Auditory Nerve. 

1. Polyneuritis. 

Gentlemen: — In the course of our lecture on post infectious laby- 
rinthitis we repeatedly mentioned that the auditory nerve is almost in- 
variably involved in inflammatory diseases of the cavities of the laby- 
rinth, especially if they are of a purulent character. Besides that we 
know of a form of hard hearing and deafness which is 'confined to in- 
flammation and destruction of the nerve, leaving the labyrinth intact. 
This disease belongs to the large class of polyneuritis, as it attacks both 
auditory nerves as a rule. We distinguish three forms as to their eti- 
ology, a. post infectious polyneuritis, b. constitutional, and c. toxic 
polyneuritis. All three forms may attack either vestibular or the coch- 
lear branches of both nerves, or they may attack both branches simul- 
taneously. The diseased part is usually found in the main stem of the 
nerve, as in a diseased optic nerve. The diseased stem becomes infil- 
trated, swells up, and the nerve fibres perish. The connective tissue 
between the fibres proliferates and takes the place of the nerve fibres ; 
sclerosis develops. In other cases degenerative processes prevail. 
What part the cochlear ganglia take remains to be decided by further 
investigations. Opinions differ on this point, as well as on the patho- 
logic anatomy of retrobulbar neuritis of the optic nerve. 

a. Polyneuritis acustica of consumptives is the best known of all 
diseases of the auditory nerve due to infectious diseases. The clinical 
picture and anatomical phenomena of this disease were first described 
by myself. A polyneuritic inflammation and degeneration of the audi- 
tory nerve occurs through the blood in rare cases as a concommitant to 
extensive tubercular processes which run a pernicious course accom- 
panied by fever. It concerns either the cochlear nerve alone or the 
whole stem of the auditory nerve. Simple atrophic changes of the 
part of the nerve in the labyrinth, besides the intralabyrintheal disease 
of the stem, are observed in those rare cases where the patient lives for 

281 



282 Polyneuritis of the Auditory Nerve. 

some time after deafness has set in. The clinical symptoms in the ear 
consist of rapid loss of hearing leading in a very short time (days or 
weeks) to complete deafness in both cars. The beginning is most fre- 
quently acute, rarely slow. Subjective noises occur frequently but not 
always. The loss of hearing is connected with serious dizziness in the 
rare cases where the vestibular nerve is also affected. 

The tympanic membrane and the middle ear as a whole remained 
normal in all cases that were observed up to date. I saw a permanent 
deafness in one ear develop acutely in a man with healthy lungs, dur- 
ing tuberculosis of the glands in the axilla accompanied by fever. 

Polyneuritis of the auditory nerve may also be the cause of deaf- 
ness in typhoid fever according to the histologic findings in a case which 
was in our institution. Clinical observations seem to show that the af- 
fection remains confined to one ear in at least one-half the cases. It is 
hardly doubtful, but not absolutely verified by pathologic anatomical in- 
vestigations, that polyneuritis plays an important part in other affections 
of the inner ear observed after acute infectious diseases, especially 
scarlet fever and influenza. There is, however, an accurate report of the 
pathologic anatomical conditions in the inner ear of an old man who 
suffered from progressive deafness after acquired lues. Lymphomata 
were found in the main stem of the auditory nerve, besides the residues 
of a labyrinthitis. New investigations seem to confirm the fact that the 
changes in the nerves in tabes belong also to postsyphilitic affections of 
the nervous system. Progressive hard hearing is observed in 2 to 10 
per cent of patients suffering from tabes. It is less due to polyneuritic 
processes than to atrophy and gray degeneration of the stem of the audi- 
tory nerve (more rarely of the intramedullary part of its central course). 
It may occur at any stage of the main disease. It is usually observed in 
both ears and is accompanied by severe subjective noises. 

b. The most important details concerning deafness in connection 
with leukaemia were given before. It forms almost the only pathologic 
anatomical example of a polyneuritis due to constitutional causes. We 
want to add that several cases of leukaemic deafness in both ears are 
known where the labyrinth and the stem of the auditory nerve were 
intact, but the medullary part or the nuclei of the auditory nerve were 
leukaemically infiltrated. We must presume that diabetes, gout, ma- 
laria, cretinism, arteriosclerosis, and senility play an important role in 
diseases of the auditory nerve as they do in other nerve regions. As a 
peculiar fact it must be mentioned that we found progressive nervous 
deafness in patients who were not tubercular, but suffered from ozena, 
and in youthful- individuals coming from families which have a poor 
health record and often show deaf -mutism, psychoses, and especially 
tuberculosis, yet present no other etiological factors. There is one more 
pathologic anatomically carefully examined instance of deafness com- 
ing under this heading, namely in carcinoma. It concerns a woman suf- 



Polyneuritis of the Auditory Nerve. 283 

fering from progressive spongifying of the capsule of the labyrinth, 
with ancylosis of the stapes. She became acutely deaf during the de- 
velopment of a carcinoma of the liver which led to death. We found 
circumscribed small cell infiltrations in her auditory nerves at our mi- 
croscopic examinations. 

Therapy is powerless in most of these cases. 

c. The nature of toxic polyneuritis has been revealed by recent 
experimental investigations. The inflammatory changes extend in these 
affections over the stem and the ganglia of the cochlear and vestibular 
nerves. Hard hearing caused by taking quinine and preparations with 
salicylic acid are daily experiences to the busy practitioner. The in- 
juries that alcohol and tobacco may inflict upon the auditory nerve are 
less known. The patients usually complain about a certain degree of 
hard hearing and a feeling of dizziness if quinine and salicylic acid are 
prescribed in doses large enough to cause serious ringing in the ears.. 
Bone conduction is considerably diminished, and symptoms on the part 
of the middle ear are totally absent. All symptoms disappear promptly 
after the patient stops taking the medicine, and no serious damage re- 
mains. Permanent injury may be done after long continued use of 
abnormally large doses. We must however be careful in accepting such 
statements by the patients, as they are often suggested to them by pre- 
vious examinations. This is especially evident in cases of uncomplicated 
progressive ancylosis of the stapes showing considerable prolongation 
of bone conduction, and a large defect of hearing at the lower end of 
the sound scale, where the patients frequently asserted that they were 
previously treated with salicylic acid and quinine. Hard hearing in peo- 
ple who lived for a long time in the tropics, suffering from malaria, and 
consuming therefore much quinine, is probably not primarily due to a 
toxic neuritis but to injury to the auditory nerve by malaria. 

A number of cases are reported of injury to the labyrinth due to 
tobacco. Alcoholic intoxication is of much greater importance to the 
nerve. I saw typical cases in two students who had consumed excep- 
tionally large quantities during several weeks. They consulted me on 
account of moderate hard hearing in both ears, which had developed 
rapidly, and showed the functional character of an affection of the laby- 
rinth. One of the cases was complicated by paresis of the oculomotor 
nerve. Complete recovery took place in both cases after ab- 
stinence. In a third case concerning a night watchman, who for many 
years was in the habit of drinking a large amount of whiskey, deafness 
occurred rather suddenly accompanied by serious symptoms, consisting 
of dizziness and noise in the ears, which disappeared only partially. 

Our knowledge of deafness from inspiration of coal gas, from in- 
toxication with lead, arsenic acid, and other kinds of poison is abso- 
lutely defective, as such cases are rarely observed. The same must be 
said about intoxication from oil of chenopodium. 



284 Degeneration of Avid. Nerve on Ace. of Dis. in Its Surroundings. 

d. A paresis of the auditory nerve of one or both ears was fre- 
quently observed in juvenile and old individuals of both sexes. It was 
due to neuritis and could not accurately be placed in one of three 
classes just described. We may, in short, call it an essential form of 
neuritis of the auditory nerve. It usually sets in with violent noises, 
dizziness, and very hard hearing or deafness ; sometimes there is vomit- 
ing, and frequently the beginning is foudroyant, showing Meniere's 
complex of symptoms. Dizziness is sometimes absent. In such cases 
the rotation test also showed normal nystagmus reaction. Attacks of 
Meniere's symptoms may exceptionally repeat themselves later on at 
different intervals. Infectious diseases, anomalies of constitution, abuse 
of alcohol could be excluded as etiological factors. The disease oc- 
curred mostly in otherwise healthy and strong individuals. It is usually 
a benign process. This is shown by the fact that recovery usually 
takes place, often after a few weeks only, by the continual use of large 
doses of antipyrin (4-5.0 a day). Quinine, if antipyrin does not act, 
may be given in large doses (i. e., 3x0.25 a day) during 10 days. 

2. Degeneration of the Auditory Nerve on Account of 
Diseases in Its Surroundings. 

Progressive deafness may of course result from proliferating in- 
flammations of the bone and periostium of the base of the skull when 
they compress the auditory nerve by narrowing the lumen of the nerve 
canals. Luetic processes may be named here, and especially a rare but 
characteristic disease of the bones of the skull called leontiasis, which 
leads to blindness and deafness. 

An affection of the inner ear was briefly mentioned in connection 
with otosclerosis. It occurs in both ears, begins in juvenile age, and is 
mostly noticed in women. The anatomical base is a spongifying of the 
bony walls of the labyrinth. It usually leads to ancylosis of the stapes 
since it is generally located in the vicinity of the oval window, and 
shows the functional symptoms of disease of the middle ear. There 
are however cases, though comparatively rare, which show in one ear 
the functional symptoms of ancylosis of the stapes, while in the other 
ear those of affection of the inner ear. In other rare cases the wall of 
the labyrinth appears typically pinkish through the normal, but extra- 
ordinarily delicate, tympanic membrane, and the hereditary conditions 
as well as the anamnesis coincide with the diagnosis. In such cases we 
do not find in either ear the functional symptoms of disease of the mid- 
dle ear but the typical symptoms of an affection of the labyrinth. 
Finally we find middle ear and labyrinth symptoms combined in the 
same ear. This is even the rule in older cases which have lasted for sev- 
eral decades. The disease of progressive spongifying, taking the form of 
nervous deafness, is always from the beginning accompanied by very 
disagreeable noises and attacks of dizziness. The presence of the above 



Cerebral Diseases as Causes of Disturbances of Hearing. 285 

named symptoms support the diagnosis in those cases, namely, heredity, 
occurrence in juvenile age, in female sex, pinkish promontory, normal 
conditions in the retro-nasal space and in the cartilaginous tube. 

I treated two sisters at nearly the same time for progressive hard 
hearing; one of them showed the functional phenomena of ancylosis of 
the stapes, the other of pure nervous deafness, while the anamnesis and 
the findings at the inspection pointed distinctly to spongifying of the cap- 
sule of the labyrinth. 

The only treatment which so far showed any favorable effect in 
spongifying of the capsule of the labyrinth is phosphorus in very 
small doses. It seems in many cases to influence favorably the process 
in the bone which has a certain similarity to osteomalacia, though it is 
not identical with it. We cannot promise our patients an improvement 
but gradual cessation of the progress, if they use it for several years. 
This takes place in at least 50 per cent of all cases, according to my ex- 
perience. The phosphorus may be given in Kassowitz emulsion 
0.02:200.0 one tablespoonful twice a day during the cool seasons. Dur- 
ing the warm seasons and in traveling it should be taken in capsules 
(phosphorus 0.00 1 : oil 0.6), two a day. The patients are able to take 
it without inconvenience. Small changes in the distance of hearing, 
improvement and the opposite belong to the clinical picture, and must 
not be attributed to the treatment. Subjective noises seem to be influ- 
enced the least. We often see other disturbances of the nervous sys- 
tem, which are independent of the disease of the ear, disappear during 
such a long treatment with phosphorus. Injections of thiosinamin or 
fibrolysin have no effect according to our experience extending over a 
series of typical cases which have all used the cure to its end according 
to the rules. 

3. Tumors of the Auditory Nerve. 

Tumors of the stem of the auditory nerve and its surroundings are 
not very rare. They are mostly psammoma and neurofibroma ; while 
glioma, sarcoma, endothelioma, etc., are less frequent. They lead to 
paralysis of the cochlear, vestibular and facial nerve, having been pre- 
ceded for some time by symptoms of irritation. The tumors grow into 
the labyrinth by destroying the bone, if they are of a malignant nature. 

Cerebral Diseases as Causes of Disturbances of Hearing. 

Besides tumors, embolisms and hemorrhages are important factors 
as diseases of the central parts of the auditory nerve. 

You know that the lowest central nuclei of the cochlear nerve are 
situated on both sides in the caudal parts of the region of the pons. 
The fibres run from there, with repeated incomplete decussation in the 
tegmentum, upward toward the lateral ventral part of the region of 
the corpora quadrigemina ; from there through the superior peduncles 



286 Midbrain Deafness. 



and through the corpus geniculatum internum, then, passing under- 
neath the rear part of the optic thalamus to the capsula interna they 
finally reach the cortex of the temporal lobe. Partial decussation of the 
fibres of both sides takes place -in various parts of this course. This 
explains the fact that a one-sided lesion of the central course of the 
auditory nerve does not cause deafness of the contralateral ear. A 
number of cases of deafness of both ears are known from diseases of 
the center of hearing in both temporal lobes, but a material and perma- 
nent decrease of hearing was never ascertained in the other ear when 
there was a destruction on one side of this region, or of the crus cerebri. 

A serious impairment of hearing in both ears from the beginning 
occurs as a rule if both central tracts of the auditory nerves sustain a 
lesion at the place where all their fibres come close together, namely in 
the midbrain. It is therefore justifiable to speak about midbrain 
deafness, similarly to cortical deafness. We have to discuss midbrain 
deafness more carefully, as it offers a number of peculiar characteristics 
besides the fact that it concerns both ears and occurs comparatively fre- 
quently. 

Tumors of the midbrain produce disturbances of hearing more 
frequently than diseases of any other region of the brain. According 
to a compilation, which has, however, no claim to accuracy as to the 
examination of hearing, tumors of the cerebellum cause pronounced 
difficulty of hearing, or deafness, in 20 per cent of cases ; tumors of the 
pons in 25 per cent, and tumors of the midbrain in more than one-third 
of the cases, namely in 34.5 per cent. The difficulty of hearing in those 
cases is produced by a lesion of the region of the lemniscus of the teg- 
mentum which is somewhat lateral and below the lamina quadrigemina, 
but not a lesion of the lamina quadrigemina itself, as I demonstrated 
conclusively in a large number of cases. Deafness occurs comparatively 
late in the development of tumors of this region, which includes tumors 
of the pineal gland. 

The first symptoms which are always present are head-ache, de- 
crease of the function of the optic nerve, irritability and, in the major- 
ity of cases, a short apoplectic attack. Later on there are changes in 
speech (dysarthria, difficult articulation) disturbance of the movement 
of the bulb of the eye, ataxia, epileptic attacks, disturbances of the mo- 
tility of the body and of the extremities, and paralysis of the facial 
nerve. Other disturbances occur less frequently, such as incontinentia, 
disturbances of the reflexes of the tendons and muscles, paralysis of 
swallowing, disturbances of sensibility in the trunk and extremities, 
polyphagia, elevation of temperature. 

Hard hearing is rarelv noticed at the end of the first month; it usu- 
ally sets in 3 to 6 months after the beginning of the disease. It gener- 
ally occurs simultaneously in both cars. How rapidly deafness pro- 
gresses depends principally upon the nature and rapidity of growth of 



Tumors between the Cerebellum, the Pons and the Medulla. 287 



the tumor. Bone conduction is shortened in the beginning, and ceases 
altogether later on. I examined one case with the sound scale and 
found that the power of perception was first lost almost exclusively for 
the lowest sounds, later on equally for all sounds of the scale. In both 
ears the defect of hearing progressed from the lower and upper limit 
so that finally only an island was left, as it is observed in the highest 
degrees of diseases of the sound perceiving apparatus, namely, of the 
stem of the auditory nerve as well as the labyrinth. 

Subjective noises are complained of in scarcely one- fourth of the 
cases. They were of three different qualities in my patient and an- 
noyed him exceedingly. Dizziness is not complained of by bed ridden 
patients. It only apparently becomes a factor in the clinical picture by 
forming a part of the complex of symptoms of ataxia. Unsteadiness in 
walking and standing {Romberg's phenomenon) should be distin- 
guished from dizziness attributed to the semicircular canals. 

The diagnosis of an affection of the midbrain can be safely made 
if progressive hard hearing is added to the above named symptoms, 
which have in the foreground those of the optic, oculomotor and ab- 
ducens nerves especially if also attactic gait develops. Tumors must 
almost exclusively be thought of, while hemorrhages and foci of soften- 
ing of the brain need hardly be considered. In children below 10 years 
they are as a rule tubercles, during puberty and in adults glioma and 
sarcoma. Gumma is rather rare in this region ; only a few were ob- 
served. I saw two cases of luetic ophthalmoplegia combined with pro- 
gressive hard hearing. Both recovered after general treatment which 
was begun very early. Almost all symptoms, also hard hearing, dis^ 
appeared later on, except some very insignificant residues. 

The prognosis of deafness due to disease of the midbrain is always 
very bad except in very fresh luetic diseases. 

The attention of neurologists has lately been repeatedly drawn to 
a certain form of tumor of the pons showing characterictic symptoms. 
They are the tumors developing in the angle between the cerebel- 
lum, the pons, and the medulla oblongata and are principally neu- 
rofibroma, but also gumma, glioma, sarcoma, psammoma, fibrosarcoma, 
endothelioma, etc. They usually occur on one side only; rarely on both. 
The neurofibromata are usually complicated by more or less extensive, 
multiple tumors of the nerve roots and nerve trunks. Most of these 
tumors originate from the nerves which pass through that angle, espe- 
cially from the auditory and facial nerves, rarely from surrounding parts 
of the brain. 

Deafness is usually confined to one ear, namely the ear correspond- 
ing to the location of the tumor, and is in the foreground of the clinical 
picture as to time of its occurrence and as to intensity. The fact that 
deafness is confined to one ear, the very early appearance of dizziness, 
nystagmus, paralysis of the facial nerve and difficulty of swallowing, dif- 



288 Tumors between the Cerebellum, the Pons and the Medulla. 

ferentiate this kind of tumors very distinctly from tumors of the region 
of the corpora quadrigemina, which show ophthalmoplegia in the fore- 
ground of the clinical picture. Subjectively and objectively noticeable 
symptoms originating from the optic nerve are evident in the same man- 
ner from the beginning in deafness caused by tumors in the pons, and 
deafness caused by tumors in the midbrain. The diagnosis of a central 
neurofibroma is sometimes facilitated by the simultaneous occurrence of 
neurofibromata in the skin. 

It was shown that it is possible to operate such tumors, if they are 
confined to one side. These attempts were, however, only very excep- 
tionally successful. 



LECTURE XXXI. 

Hysteria and Traumatic Neurosis of the Auditory 
Nerve Apparatus. 

Gentlemen: — Hysteria and traumatic neurosis, which is a mixture 
of hysteria and neurasthenia, must be classed in a certain respect with 
central diseases. 

Hysterical symptoms are rather exceptional in the organ of hear- 
ing. They are recognized as such from the fact that they appear in 
direct connection with, or some time after, some serious excitement, or 
other influences which may injure the whole organism, or after a com- 
paratively slight traumatism in an otherwise normal ear, or after a pre- 
ceding affection of the ear which is, however, well healed. The patients 
are usually women who have a hereditary tendency towards nervous dis- 
eases. Sometimes they are older children, but the strongest disposition 
is found in those years when the sexual functions develop and are at 
their hight. The complaints are sometimes of pain in the ear, in the 
depth of the auditory canal, or in the mastoid process (mastalgia) ; 
other times they are of different degrees of hard hearing, or deafness, 
usually in both ears. The picture may be complicated by passing dumb- 
ness, noise in the ears, feeling of dizziness, head-ache. The diagnosis 
may be supported by the presence of other symptoms of hysteria, which 
may be of a purely psychical nature, or which may belong to the sen- 
sitive or motor sphere, as, for instance, sudden change of the symptoms, 
sudden changes for the better or for the worse, for which there is no 
apparent reason. In affection of one ear only we may be able to produce 
the phenomenon of the transfert by magnetotherapy or metallotherapy. 
Functional tests may sometimes give results which are somewhat simi- 
lar to those in a real organic lesion, sometimes they contradict our 
physical suppositions, thereby putting us on our guard. (We refer to 
page 243 as to the abnormal desire for operations of many hysterical 
patients.) 

Traumatic neuroses are partially of a purely hysterical nature, and 
subject to peculiar changes in kind and intensity, just as are hysterical 

289 



290 Injuries to the Inner Ear. 

neuroses. In that case they cannot be differentiated from the clinical 
picture just described. The suspicion of a real lesion, or at least of a 
serious functional disturbance, can, however, not be discarded if func- 
tional tests in a case of deafness or hard hearing always give the same 
results in every new examination, even if the course of the examination 
is changed. An important question in making a diagnosis is whether 
the trauma really corresponds to the present symptoms, and whether the 
symptoms developed soon after the accident, or, on the other hand, 
whether the clinical picture of neurasthenia was not produced by per- 
manent suggestion or auto suggestion, caused by constant fear of per- 
manent injury, because this' anxiety may be sustained by the real pres- 
ence of some slight insignificant symptoms in the ear. The diagnosis 
in such cases is sometimes very difficult, and can be made only after 
long observation in connection with a competent neurologist, who some- 
times is able to throw light on doubtful cases. 

Injuries to the Inner Ear. 

Direct injuries to the inner ear, except from shots, are very rare 
on account of the protected position of the labyrinth. Indirect injuries 
caused by concussion, or blows, or falling on the skull, are much more 
frequent. Injuries to the inner ear from sudden and great changes of air 
pressure in the external meatus, are also considered among the indirect 
injuries. The most frequent injury to the inner ear is that from excessive 
noise, the acoustic trauma. The deafness of people who work in places 
with high air pressure (caisson workers) occupies a peculiar position 
among indirect injuries. 

1. Direct Mechanical Injuries. 

We designate direct injuries those from stabbing, operations, cau- 
teries and shots. The labyrinth can be injured by stabbing from the 
meatus only through the oval window. The facial nerve passes directly 
above the upper margin of the oval window, and has at this place a very 
thin covering of bone, which often shows dehiscencies. Paralysis of 
the facial nerve is therefore not rare in this form of traumatism. Knit- 
ting needles, tooth-picks, and other pointed objects which are used to 
scratch the external canal, may pierce the tympanic membrane and the 
oval window, if an unexpected shock against the elbow pushes the hand 
abruptly toward the head, during scratching. This form of injury is 
not very rare. Similar injuries may be produced by forcible stabbing 
with a knife. They are rarer, I saw only one of them. The injured 
person usually falls down unconscious after a trauma of this kind. Fluid 
escaping from the labyrinth is observed only in a fraction of these cases. 
Dizziness of the highest degree, vomiting, noise in the ears are always 
complained of. All these symptoms usually disappear again after a 
varying length of time, but the ear remains deaf, and the paralysis of 
the facial nerve is often permanent. 



Direct Injuries to the Inner Ear. 291 

A prolonged suppuration of the middle ear is rarely observed in 
connection with such traumatisms. They are the rule after extensive 
cauterisations of the external canal which have been intentionally in- 
flicted in order to produce unfitness for military service. These occur- 
rences, together with their consequences, fatal hemorrhages, etc., were 
described in an earlier chapter (page 129). 

Unintentional direct injuries of the labyrinth and of the facial nerve 
occur sometimes in radical operations, especially if the anatomical con- 
ditions are changed by preceding osteitic processes and former opera- 
tions. These are the only two conditions under which such a serious 
mistake may be excused. The external semi-circular canal is often exposed 
to this same traumatism, especially at the spot where, in the aditus above 
the facial canal it is only very little below the surface. The consequence of 
opening of the endolymphatic space is probably complete deafness, fre- 
quently violent dizziness lasting for many weeks. The same result is usually 
produced by the unintentional removal of the stapes, which sometimes 
happens to otologists during the coarse procedure of the so-called evi- 
dement of the tympanic cavity, sometimes by unsuitable attempts at re- 
moval of foreign bodies from the meatus and tympanic cavity. 

Gun shot injuries of the inner ear are usually compound fractures 
of the skull. Every bullet upon entering the labyrinth bursts the pyra- 
mid. The effect of modern fire arms consists in shattering the bone at 
least to the dura, and in shots fired at close range, fatal injury to the 
brain. Revolver shots fired with suicidal intent into the external meatus 
are usually directed more backwards, not against the labyrinth, so that 
the bullet may advance towards the posterior cranial fossa. It may be 
stopped on its course by the hard masses of bone of a sclerosed mastoid 
process. Fissures of the bone may reach the labyrinth, causing thereby 
an indirect injury. Rifle shots into the labyrinth were observed where 
the bullet entered from the region of the zygoma or mastoid process, or 
from the mouth or nose, and passing transversely through both mastoid 
processes, caused deafness in both ears. Partial and even complete deaf- 
ness may be caused by ricochet bullets, or grazing shots, by the simple 
concussion, or by fractures in the bone. Injuries from bullets which 
reached the pyramid probably always cause complete deafness. They 
are often complicated by paralysis of the facial nerve, and shattering of 
the joint of the jaw. 

The bullet must be extracted or chiseled out, if it is evident that it 
remained in the mastoid process, either from the nature of the injury 
or from x-ray examinations. Conservative treatment is out of place 
here. The numerous spaces in the temporal bone containing air, explain 
the fact that a bullet never becomes enclosed as in other parts of the 
body, but always causes a suppuration which lasts as long as the foreign 
body remains in the depth, and may lead to a fatal meningitis, or through 
sinus phlebitis, to pyemia, even after many weeks and months, as ex- 
perience has shown. 



292 Indirect Injuries to the Inner Ear. 

Instillations of fluid and syringing of the ear have to be avoided in 
gun shot wounds as in all injuries. 

2. Indirect Mechanical Injuries. 

There is usually a fracture of the temporal bone or of the bony 
labyrinth, where deafness resulted from the impact of a dull force, as 
a fall, blow, or stroke on the head. There are post mortem results 
which show that sometimes a simple fall, striking the head on flat 
ground, may prove sufficient to cause a fracture through both labyrinths, 
and total deafness. Large statistical investigations (in the clinic in 
Zurich) show that the labyrinth participates in one-fourth of all frac- 
tures of the base of the skull. It is rare that a fracture is exclusively 
confined to the pyramid. Both labyrinths are concerned in one-seventh 
of the cases which survive. The fissures in longitudinal fractures, and 
in transverse fractures of the base of the skull, usually run in the direc- 
tion of the impact of the force (fractures from bursting). Fractures 
due to flexion are observed less frequently. The fissures run in a per- 
pendicular direction to that of the impact. We sometimes find a simple 
fissure, sometimes several fissures in different directions ; in other 
cases a complete destruction, corresponding to the intensity of the force. 
The original direction of the fissure in children deviates, if the fissure 
crosses a bone suture. The fissures follow the suture after the crossing. 
That is one reason why fractures of the labyrinth are rare in children. 
The thinner and softer parts of the temporal bone in adults are more 
frequently fractured than the labyrinth itself. Longitudinal fractures 
avoiding the pyramid, are often observed. They start in the middle 
cranial fossa, pass over the roof of the tube or the tympanic cavity, and 
continue in the rear cranial fossa, following along the sulcus of the 
sigmoid sinus. Perforated parts of the pyramid, which are in its median 
part the spongy apex, and in its lateral parts the pneumatic spaces, con- 
stitute the favorite places for transverse fractures. Fractures passing 
through the labyrinth are compartively frequent. They follow the cavi- 
ties of the labyrinth and the porus acusticus internus. 

A subdural hemorrhage ocurring in another place may produce the 
symptoms of a laceration of vessels in the labyrinth, even though there 
is no fracture of the pyramid, the blood running along the perineural 
lymph spaces and through the aquaeductus cochleae into the labyrinth. 
Paralysis of the facial nerve shows in half the cases, and discharge of 
cerebro-spinal fluid in about one-fifth. Lesions of other nerves besides 
the facial are observed less frequently, and concern the abducens, ocu- 
lomotor, trochlear, glosso-pharyngeal and the vagus nerves. Hemor- 
rhage from the carotid artery or sinus are mentioned but rarely in con- 
nection with fractures ; likewise emphysema of the same side of the 
neck. 



Indirect Injuries to the Inner Ear. 293 

The complication of an indirect injury to the labyrinth, with sup- 
puration of the middle ear, is not very often observed. The cause is 
usually the entrance of fluid during an injury to the tympanic mem- 
brane or the wall of the external meatus. 

The most important symptoms of an injury to the labyrinth are 
deafness, subjective noises and dizziness. The diagnosis is sometimes 
supported by profuse hemorrhages from the meatus lasting for a long 
time, while the anterior wall of the meatus is intact ; furthermore by a 
discharge of cerebro-spinal fluid which can easily be distinguished 
from fresh secretion of the middle ear owing to the large amount of 
salt and small amount of albumin which it contains. Sometimes masses 
of brain appear in the external ear, in other cases we see extensive 
bloody sugillations of the parietal and mastoid region of the eyelids and 
the conjunctivae, more rarely of the occiput. 

About one-half of the patients injured in this manner die during 
the first 48 hours from destruction of parts of the brain, hemorrhage 
into the ventricles of the brain, oedema of the brain and complications 
in the lungs. The greatest danger during the next few days or weeks 
is meningitis starting from suppuration of the labyrinth. 

The consolidation of the fracture takes place very slowly and with- 
out formation of a callus. The fragments are sometimes united by con- 
nective tissue only. The membranous labyrinth succumbs in the region 
of the fracture, granulation tissue develops in its place, which leads in 
the further course to complete and permanent filling up of the cavities 
of the labyrinth by bone and connective tissue. The final result is the 
same as we have seen in labyrinthitis after infectious diseases. 

According to this the prognosis is bad as to recovery of the power 
of hearing after a fracture of the labyrinth. Subjective noises usually 
remain, while dizziness as a rule is annoying in the beginning only. It 
disappears completely later on, or is noticeable only occasionally, for 
example in stooping or in looking in different directions. 

Hearing may be seriously interfered with. Subjective noises and 
dizziness may occur as the result of some outside force affecting the 
skull which did not cause a fracture of the pyramid or of the skull. 
These symptoms are due to shaking of the labyrinth and brain and are 
called commotion of the labyrinth or brain. Of course we can only 
surmise as to how far this clinical picture is due to multiple hemor- 
rhages in the auditory nerve and labyrinth, which were repeatedly ob- 
served in such cases. They may also be due to a tearing of some of the 
nervous elements which are fixed in so many different manners. 

The prognosis is unfavorable if the disturbances do not disappear 
within the first few days. In some cases these symptoms disappeared 
after some time. They were of a hysterical nature, caused by shock and 
excitement. 



294 Acoustic Traumatism. 

3. Acoustic Traumatism. 

We must differentiate acoustic traumatism into: 

1. A form of injury to the labyrinth caused by one short sound 
like a detonation, explosion, whistle of a locomotive. 

2. A form caused by frequently repeated loud noises. 

The most frequent of the first kind of injuries are those from 
shots, which are most injurious to the ear, when it is close to the barrel 
of the rifle, or when the detonation takes place in a closed room. Even 
small rifles when used in a room are not at all harmless. 

The consequences of the second kind of acoustic traumatism are 
called "professional hard hearing." Blacksmiths, boiler-makers, coop- 
ers, tinsmiths, locksmiths, cabinet-makers, people who work in noisy 
factories, locomotive engineers, firemen, lose a part of their power of 
hearing in the course of years. 

Hearing tests in both forms of hard hearing show the loss of hear- 
ing of a variably large part at the upper end of Galton's whistle. 
Sharp shooters always suffer from this defect. The lower limit is in- 
tact, they hear as low as 16 v. d. and lower, provided that the conditions 
are otherwise normal. 

Subjective noises are hardly ever absent in injuries to the sound 
perceiving apparatus, while in the majority of cases of professional 
hard hearing they are absent. They are always present in people who 
became hard of hearing from detonation or shrill sounds, etc., and have 
usually a high pitch like singing, ringing, whistling. A continuation of 
the sound of the same pitch as that which caused the trouble is fre- 
quently complained of together with a hyperaesthesia for the same 
sound. Noises which occur as the effect of one strong sound usually 
disappear again later on, while those after mechanical injuries to the 
labyrinth remain the same. 

Dizziness and interference with equilibrium which are a regular 
symptom in injuries to the labyrinth may occur sometimes as the effect 
of detonations, but are usually absent in people who are hard of hear- 
ing from their occupation. 

There is so far one microscopic finding known of professional 
hard hearing. It concerns a boiler-maker and corresponds to the ana- 
tomical picture of what was described as presbyacusis : atrophy of 
Corti's organ and the corresponding branches of the auditory nerve. 

The prognosis of professional hard hearing is bad as to improve- 
ment, and a progress of the process can be stopped only by giving up 
the noisy occupation. The prognosis of hard hearing after detonations 
depends upon the intensity of the acoustic traumatism. The feeling of 
deafness and the ringing may disappear after hours or days, they have 
even disappeared after months and years, but they may also remain 
permanent. An otherwise diseased inner ear is specially sensitive to an 
acoustic traumatism. 



Electric Traumatism. Caisson Deafness. 295 

4. Electric Traumatism. Caisson Deafness. 

Electric traumatisms to the acoustic nerve without any noticeable 
injury occur sometimes from strokes of lightning, or through the tele- 
phone during a thunder storm. 

A peculiar and serious injury to the labyrinth was repeatedly ob- 
served in men working in caissons, when they changed too fast from 
high to low air pressure. The blood absorbs a much larger volume of 
air through the lungs while the person is under high air pressure in the 
caisson, than under the general outside pressure of one atmosphere. 
The additional volume of air and gases is set free inside the blood ves- 
sels and forms bubbles when the air pressure is lowered too rapidly in 
leaving the caisson. The bubbles do not only form in the blood vessels 
but also in the large lymph spaces of the central organs, where they 
may cause serious mechanical lesions and extensive disturbances of 
nutrition. Lesions of the organ of hearing were observed from many 
minutes to several hours after an imprudent exit from the caisson. 
The lesions consisted of a sudden attack of dizziness, ringing, deafness, 
vomiting and a feeling of extreme weakness. These symptoms may oc- 
cur in one or both ears, and sometimes disappear after a few days. 
Deafness however usually remains permanent. The pathologic anatom- 
ical changes that were observed on animals, who were of course exclu- 
sively used for such experiments, consisted of perivascular extravasa- 
tions in the scales of the cochlea and in the semi-circular canals. In 
the cases of deafness that became known there were probably exten- 
sive embolisms of gas in the blood vessels of the labyrinth and in the 
lymph spaces. 

The best therapeutic procedure in such a case is probably the 
quick return to the high pressure chamber. 



LECTURE XXXII. 
Deaf-Mutism. Education of Deaf-Mutes. 

Gentlemen: — The defects in the organ of hearing which develop 
either during the embryonal period or during infancy, leading to rela- 
tive or complete deafness, prevent the patients from learning to talk. 
Some of these defects are due to anomalies of development during the 
embryonal period, others to partial or total destruction of the organ of 
hearing in the course of a number of general diseases, or purely local 
diseases of the ear during the first few years of life. 

Deaf and dumb children are usually brought to institutions for their 
education between their seventh and eighth years. The general disease, 
as well as the local process in the ear, is healed in the large majority of 
children with acquired deaf-mutism. All hopes formerly cherished of 
curing or improving deaf-mutes by electricity, etc., have long ago been 
recognized as illusory. 

Otologists therefore limited their endeavors to the statistics of deaf- 
mutes in and out of institutions. A close connection between otologists 
and deaf-mute institutions developed only within the last decade. 

As soon as otologists began to study deaf-mutes we learned that a 
considerable number of them have remnants of hearing which enable 
them to hear vowels and even words. 

Careful investigations of these remnants by means of accurate in- 
struments, and their connection with understanding of speech, showed 
that about one-third of all deaf-mutes in institutions have sufficient 
hearing upon which to base a method of education which allozvs them to 
use their ears, together with their eyes, which were long used for lip 
reading. The method of education of each newly entering pupil is va- 
ried according to the degree of hearing that he possesses. It became the 
task of the otologist to carefully test the hearing of each pupil, and to 
decide to what extent he could make use of his ears for education. 
You will see later on of what importance these examinations are for the 
future of the pupils. 

First allow me to give you a summary of the statistical results of 

296 



Statistics of Deaf-Mntes. 297 

the investigation of deaf-mutes. A large number of otologists took an 
important part in their compilation. 

The acquisition of these statistics involved many difficulties, such 
as will always be encountered in the collection of similar material. The 
line between hard hearing and deaf-mutism is determined by the impos- 
sibility in the latter class, of learning how to speak either at home or in 
the public schools. The children are gathered in the deaf and dumb 
institutions and there we find a large number of more or less hard- 
hearing children, besides those who were deaf since their birth, or since 
their first years of life. 

A number of other points are important for the development of 
speech and the retention of what these children have learned. They 
are the degree of the defect of hearing, the time when it developed, the 
intellectual condition of the child and how much time was given to him 
at home and in school. It happens that children who became deaf in 
their twelfth year and later lose entirely their power of speech, while 
others who became absolutely deaf at eight and earlier retain their 
power of speech owing to incessant endeavors on the part of their rela- 
tives and teachers. The relatives during the first five years usually do 
not know whether the child suffers from deaf-mutism or from slow de- 
velopment of mental capacity and speech. The census, for this reason, 
shows such a small number of deaf-mutes for the first five years of life 
that it can impossibly be correct, especially if we take into considera- 
tion that in this period of life the largest number of cases of acquired 
deafness develop, not to speak of the congenitally deaf. Besides these, 
a considerable number of older, nearly deaf children are dragged along 
in public schools where they acquire only small fragments of speech. 
We find such children in every institution for the deaf and dumb; they 
arrived at the place where they really belong, only after several years 
spent in vain efforts in public schools. Such older children also will 
not be counted as deaf and dumb in the census as long as they visit the 
public schools. There is therefore no doubt but that the figures of the 
census concerning the frequency of deaf-mutism are far below the real 
condition, especially concerning the first few years. The last census of 
Germany taken in 1900 shows among 56.367,178 inhabitants, 48,750 
deaf-mutes (10,000:8.6). Only 1,093 are children up to the fifth year, 
from five to ten 4,244. The figures for every period of five years up to 
the 40th year of life are larger. There are for example 10,500 deaf 
between 30 and 40 which abnormally large figure finds its explanation 
in the epidemic of cerebro-spinal meningitis of 1865. These figures 
prove without further comment that the greater number of deaf chil- 
dren between 1 and 5 and a very large number between 5 and 10 were 
not included in the census. 

Mygind 1 compiled the statistics of 23 European countries and 



1) Taubstummheit, Berlin & Leipzig, published by Coblentz. 1894, page 17. 



29S Statistics of Deaf-Mutes. 

found an average proportion of 10.000:7.9. The number of deaf-mutes 
in mountainous countries is much larger, in Switzerland for example, 
the proportion is 10.000.24.5. Bircher 1 studied very carefully those 
mostly congenital and endemic forms which are combined with goiter 
and cretinism. 

Different censuses give extremely varying results as to the number 
of congenital and acquired deaf-mutes in different countries. The figures 
probably do not give a correct idea of the actual condition as they vary 
between 33, and 174 acquired deaf, to every 100 congenitally deaf. 2 
The institutions for deaf-mutes and the statistics compiled by otologists 
gave less varying and more reliable figures. Deaf-mutism seems to be 
acquired in little more than half the cases according to those statistics. 

As to the age when hearing is most frequently lost from dis- 
ease, we know that the first and especially the second year of life show 
the highest figures according to Hartmann, Mygind, Uchermann and 
myself. 3 

Deaf-mutism concerns the male more frequently than the female 
sex. Mygind combined the statistics of Europe with those of North 
America and found the proportion of male to female deaf-mutes 
100:83. This proportion is however not the same for congenital and 
acquired forms. We owe the most reliable statistics on deaf-mutes to 
Lemcke. i He examined personally all deaf-mutes of the state of Meck- 
lenburg and finds a larger number of women among the congenitally 
deaf, 105:100. A preponderance of the female sex among the con- 
genitally deaf was also found by Uchermann in Norway and by myself 
in Bavaria. The larger number of males among the acquired deaf- 
mutes finds a simple explanation in the fact that boys suffer more fre- 
quently than girls from children's diseases which are liable to destroy 
the ear. The preponderance of the female sex among the congenitally 
deaf may have some connection with the other absolutely inexplicable 
law that more boys are born than girls. We might explain it in this 
way, that the female embryo is less resistant in the uterus against harm- 
ful influences than the male. 

There are peculiar conditions as to the heredity of deaf-mutism. 
A direct heredity from the parents and from the grand-parents is very 
rare. Hartman for example found it in less than 1 :iooo. Even where both 
parents are deaf, children are deaf only exceptionally. It is however 
a peculiarly frequent occurrence that two or more children in the same 
family are congenitally deaf. Hammerschlag a short while ago showed 
statistically that the frequent occurrence of deaf-mutism among sisters 
and brothers has beyond a doubt some connection with consanguineal 



1 Der endemische Kropf und seine Beziehungen zur Taubstummheit und zum Kretinismus. 
Basel, 1893. 

2 Mygind, Taubstummheit, Table I, page 13. 

3 Bezold, Taubstummheit, page 2fi, etc. 

4 Die Taubstummheit im Grosshfrzogtum Meklenburg-Schwerin. Leipzig, Langhammer, 1892. 



Heredity in Deaf -Mutism. 299 

Hartmann reports a case of five deaf-mute sisters and brothers 
whose parents, grandparents, and great grandparents were first cous- 
ins. 

A short while ago I examined one of two congenitally deaf-mute 
children whose parents were congenitally deaf-mute and had the same 
great grandfather. 

In my work on "deaf-mutism" I reported another case of two deaf- 
mute children descending from a marriage of first cousins. I found a 
third child in that same family who was deaf in one ear only. The 
mother was deaf in one ear probably congenitally. The three children 
and the mother showed at the same time the extraordinary malforma- 
tion of the eyelids, known as epicanthus, which according to several 
authors is of hereditary origin. The children were brunettes like the 
mother, while the other hearing sisters and brothers were blond. 

You know furthermore of the multiple occurrence of retinitis pig- 
mentosa, often combined with deaf-mutism, which frequently appears in 
several sisters and brothers descending from consanguineal marriages. 
Marriage of deaf-mutes may therefore be permitted, but inter-marriage 
of relatives in whose families deaf-mutism or congenital deafness of 
one ear only has occurred must be absolutely cautioned against. 

My considerations about the different etiology of acquired deaf- 
mutism are based upon a study of 233 cases 1 which I examined myself 
in the course of years. I found like all other authors that cerebrospinal 
meningitis was the general disease that caused deaf-mutism most fre- 
quently. In 74 cases of my statistics, that is in 31.8 per cent, this dis- 
ease was recognized to be the cause, either by the physician or from 
unmistakable symptoms, especially rigidity of the neck. Characteristi- 
cal disturbances of the equilibrium were present in the majority of cases 
when I saw them, or they had existed for a long time. The frequent 
occurrence of this symptom was established by Moos 2 in his statistics 
extending over 64 cases. In 47 more cases of my statistics the diagno- 
sis was most probably an inflammatory disease of the brain or of its 
membranes, as we hear comparatively frequently the diagnosis "typhoid 
fever" or "typhoid of the brain" and similar expressions. 

Cerebral processes as a whole are represented by 51.9 per cent in 
my statistics, including 74 cases. The number of deaf-mutes originat- 
ing from cerebrospinal meningitis varies at different times, probably 
on account of the change of frequency in the occurrence of the disease. 
Von Ziemssen for example for three successive years found exclusively 
victims of meningitis in the deaf and dumb institutions of Bamberg 
after the epidemic of 1865. 

Scarlet fever is next in frequency among the causes of acquired 
deaf-mutism. My statistics show 42 or 18 per cent of deaf-mutes due 



1 Taubstummheit. Wiesbaden. 1902. 

2 Ueber Meningitis cerebrospinal s. Heidelberg, C. Winter, 1881. 



300 Etiology in Acquired Deaf-Mutism. 

to scarlet fever. The tympanic membrane in people who became deaf 
from meningitis is almost always intact. In those deaf from scarlet 
fever extensive destructions of the membrane and often also of the os- 
sicles were found in 35, or five-sixths of them. The influence of large 
epidemics in different years is not as prominent in scarlet fever as in 
meningitis. 

All other infectious children's diseases put together do not cause 
deafness in both ears and therefore deaf-mutism, as frequently as the 
two just named. The above mentioned statistics show measles as the 
cause of deaf-mutism in 2.1 per cent, diphtheria in 1.7 per cent, ty- 
phoid, 1.3 per cent, pneumonia in 0.9 per cent, whooping cough and 
osteomyelitis in 0.4 per cent. These figures are so much more startling 
compared to those of deafness from meningitis and scarlet fever, since 
about twice as many children acquire measles as scarlet fever, and 
meningitis is a comparatively rare disease. 

Parotitis and hereditary lues were not sufficiently considered as 
causes of deaf -mutism in the statistics published up to the present day. 

There were four of my 233 cases of acquired deaf-mutism, or 1.7 
per cent, due to mumps. Of all statistics only Schmaltz' s of Saxony 
has 0.3 per cent and one of America shows 0.5 per cent (according to 
Mygind page 125) of deaf-mutes due to parotitis. 

Hereditary syphilis is mentioned only by Hedinger in one, and by 
Lemcke in two cases as the cause of deaf-mutism, among all accessible 
statistics. In my statistics there were 13 cases or 5.6 per cent of ac- 
quired deaf-mutes who showed one or several objective symptoms of 
hereditary lues. I found for example Hutchinson's teeth, destructions 
of the bony parts of the nose and palate, multiple exostoses on the skull, 
indolent glands, etc., and at the time that deaf-mutism began there was a 
still existing or preceding corneitis diffusa in the majority of cases. 

The reasons for the fact that the cause of deaf-mutism in heredi- 
tary lues remains frequently unknown are these : deafness in heredi- 
tary luetic children occurs usually at an age when they have learned 
how to speak (most frequently about the eighth year). During the 
time the child gradually loses his power of speech the symptoms of 
hereditary lues, especially the most characteristical one, the corneitis 
diffusa, have long disappeared. 

I found in my statistics other purely local causes for acquired deaf- 
mutism in 6.4 per cent which were due to suppurations of the middle 
ear, depending upon no general disease, and in 3 per cent traumatism 
(falling on the head). My statistics are comparatively small but they 
coincide with other larger statistics and add some important details. 

One word about the comparison of sexes. Acquired deaf-mutism 
is found much more frequently in the male than in the female, which 
is the contrary to congenital deafness. I found the proportion 100:66. 

The pathologic anatomical changes leading to loss of hearing are 
mainly confined to the labyrinth (compare page 266). 



Remnants of Hearing in Deaf-Mutes. 301 

Habermann found that the occlusion of both windows causes deaf- 
mutism. The cochlea however usually takes some part in the occlusion 
of the round window at least. There is no case known up to date 
where cerebral processes alone caused deaf-mutism. Congenital deaf- 
mutism is comparatively rarely due to anomalies of formation consist- 
ing in a complete absence of the bony labyrinth. The membranous 
labyrinth which was investigated during the last few years by Scheibe, 
Siebcnniann, Alexander and others, shows a number of peculiar anoma- 
lies which completely explain deafness. 

One case of Siebenmann is of special interest for the physiology of 
the labyrinth. The changes were confined exclusively to the cochlea, 
while disturbances of the organ of equilibrium, which is situated in the 
vestibulum and in the semi-circular canals, were absent. In the major- 
ity of deaf-mutes these disturbances are manifested by the absence of 
dizziness and nystagmus during rotation. 

The frequency of remnants of hearing and their quality and quan- 
tity could only be investigated by means of the continuous tone-series 
which produces all audible sounds sufficiently strong and pure, in other 
words free from accidental noises and overtones. 

Urbantschitsch tested the deaf-mutes of Vienna by means of a har- 
monica extending over six octaves. 1 The tones of this instrument have 
many overtones rendering a test for the perception of each tone impos- 
sible. Its tones may even be felt through the floor (Schwendt). This 
explains why Urbantschitsch found that almost no person was totally 
deaf. 

My tone series allows to completely analyze the function of the or- 
gan of hearing (compare page 53) by testing each tone. I examined 
the pupils of the institution for deaf-mutes in Munich since 1892. 
These examinations by means of the continuous tone series have since 
been repeated by a number of otologists in other institutions in Ger- 
many, and elsewhere with results similar to mine. 2 

Originally I only tried to find in the deaf and dumb institutions 
new proofs for v. Helmholtzs theory, that the cochlea alone is able to 
analyze noises into their constituent parts, by investigating the kind 
and the distribution of remnants of hearing over the sound scale. I 
found what I wanted and more. A careful hearing test of the ears 
of deaf-mutes besides being of great theoretical interest, has an unex- 
pected practical value by giving indications for teaching them to speak 
and for educating them. 

Up to 1898 I tested 276 organs of hearing of deaf-mutes. Of 
these 79 were totally deaf. The others had remnants of hearing of 
various extent. 

Both ears were totally deaf in only 27 pupils or 19.7 per cent of 



1 Ueber Horiibungen bei Taubstummheit. Wien, Urban & Schwarzenberg, 1895. 

2 Das Horvermogen der Taubstummen. Wiesbaden, Bergmann, 1896; 3 additions till 1901. 



302 Remnants of Hearing in Deaf-Mutes. 

those 138 pupils. Small remnants were found in 58 pupils. The other 
53 or 38.4 per cent showed such extensive remnants of hearing distrib- 
uted over a large part of the sound scale that they were not different 
from a large number of adult hard hearing people with whom every- 
body can converse very easily. 

Their speech, which they learned in the institution, did not differ 
materially from that of the totally deaf with whom they studied articu- 
lation, by following the motions of the mouth of their teacher. It was 
nearly as harsh, monotonous, and slow. Each sound was produced 
with similar efforts of the muscles as in the totally deaf. Their intellectual 
capacity was not above that of the others and was mainly confined to 
concrete objects. 

After ascertaining the hearing for the tone series, I began to test 
by means of speech by talking moderately loud directly into their ears. 
The pupils who heard best repeated all vowels very easily and even the 
majority of consonants. After a few attempts they were able to repeat 
whole words, most of them without the former harshness and with the 
rhythm and accent in which they were spoken into the ear. They now 
had two kinds of speech, the articulation speech which they learned 
artificially, and the natural speech taught by means of the ear. 

Some distinct unalterable relationship was found between the hear- 
ing of some sounds of speech and hearing of certain parts of the tone 
series. The sibilants were heard only by those pupils who heard the 
upper part of the tone series, the consonants R, M, N, L, only by those 
who heard tones of low pitch comparatively well. 

It became evident that by far the most important part of the tone 
series for the understanding of speech is the part from b' to g" . Every 
pupil who did not hear this small part of the whole series of tones, or 
heard the tuning forks producing those tones for a short time only (up 
to 10 per cent of their normal duration of hearing) was either totally 
unable to hear speech or understood it only very insufficiently. 

The relation between the hearing of tones and the hearing of 
speech is explained by the fact that each letter has a distinct pitch and 
that the pitch of most of the vowels and consonants is within the above- 
named limit of b'-g". Many years of experience have shown that all 
pupils who have sufficient hearing for that part of the scale, may learn 
to speak at least partially by means of the ear. This holds good even 
in those pupils who are not able to repeat a single letter at the time of 
first examination. Inability in the beginning to repeat anything they 
hear is especially found in children suffering from congenital deafness. 

Hartmann found long ago that remnants of hearing were more 
frequent in the congenitally deaf than in the acquired deaf. It is 
nevertheless a fact that congenitally deaf children meet with much 
more difficulty in learning how to speak than children who became deaf 
at an age when they had previously learned some speaking. They are 



Education of Dcaf-Mutcs Showing Remnants of Hearing. 303 

easily able to keep step as to education of speech with the others who 
have similar remnants of hearing as soon as understanding of a small 
number of words is taught them through the ear. 

It is evident that these numerous and extensive remnants of hear- 
ing which are found in more than one-third of all deaf-mutes ought to, 
be made use of for the purpose of education. The experience in all 
deaf-mute institutions showed that this is impossible in class instruction 
where the teacher is several yards away from each pupil. Each new 
word must be pronounced directly into the ear before it is absorbed 
and learned. To the majority even then a number of letters are lost 
which they must acquire by studying the mouth. For this purpose each 




Fig. 75. 

Class of partially hearing children in the Central Institution for deaf-mutes in 

Munich. 

pupil is provided with a mirror which allows him to indirectly see the 
motions of the mouth of the teacher who speaks directly into his ears. 

Fig- 75 shows you how these mirrors are used during instruction 
of a class of partially hearing deaf-mutes in the R. Central Institution 
for deaf-mutes in Munich. 

The teacher of deaf-mutes Kroiss 1 in a psycho physical study of 
this question showed how completely the methods of teaching by ear 
and by mouth supplement each other. The children during general 
instruction are able to recognize at a distance any word which they 
have learned with the eye and ear and whose meaning they* have ab- 



i Zur Methodik des Horunterrichts. Wiesbaden, Bergmann 1903. 



304 Education of Deaf-Mutes Showing Remnants of Hearing. 

sorbed. The instruction of each pupil separately requires therefore 
only a relatively short time. 

Director Roller of the deaf and dumb institution in Munich recog- 
nized from the beginning the pedagogic importance of the results of 
the hearing tests. Owing to his unprejudiced and unselfish judgment 
he recognized the short-comings of the method of general instruction 
then prevalent and admitted them unreservedly in spite of the almost 
unanimous opposition of all teachers of deaf-mutes. 

The short-comings consisted in totally excluding from instruc- 
tion the natural organ of perception of speech. Great harm was 
done to partially hearing children by forcing them, like the totally deaf, 
to go through the laborious method of learning single sounds and then 
combining them into words and sentences, while they would have been 
able to absorb easily most of the sounds and even some words through 
the ear and to pronounce them with their true accent. 

A worse consequence of the common instruction of the partially 
deaf together with the totally deaf than even the great loss of time and 
the dissatisfaction of the children with a method that did not cor- 
respond to their faculties was the direct malformation of their speech. 
The same short-comings peculiar to the speech of deaf-mutes were 
forced upon the partially hearing and their speech resembled more and 
more the speech of the totally deaf on account of daily imitation. 

Systematical "hearing exercises" were introduced by Urbant- 
schitsch together with the teachers of deaf-mutes in Vienna several 
years before the remnants of hearing were used at the institution in 
Munich, and remarkable results were obtained in improving the sound 
of their speech. There was however a strong opposition by teachers 
of deaf-mutes because he did not select his pupils and even wanted to 
include the totally deaf in his exercises. He also made promises of 
"awakening the auditory nerve" and of real improvement of hearing 
which were never realized and never could be realized on account of 
the partial destruction of the cochlea in the ears of deaf-mutes. The 
frequent and futile attempts at hearing exercises made by means of 
the harmonica brought into unmerited disrepute the real success of the 
speaking exercises. 

Credit is due to U rb ants chit sch for first introducing a systematical 
education by means of the ear, although under premises which could 
not be realized. The first separate class-room for pupils who heard best 
according to my selection was opened in Munich in 1898. The follow- 
ing year a second class room had to be opened and now there are three 
special classes for partially hearing among 90 pupils. The instruction 
in these three grades is given simultaneously by hearing and articula- 
tion. The instruction by hearing is based exclusively on the remnants 
of hearing which are present. These remnants can not be increased, 
but according to our experience, they are sufficient in themselves to 



Hard Hearing and Diseases of the Ears in Schools. 305 

build upon them a natural speech transmitted by means of the ear. Of 
course the eye cannot be dispensed with nor can the instruction in ar- 
ticulation. The director of the institution sums up his experiences 
since 1898 with the separate classes for hearing in his yearly report of 
1901 to '02 in these words: These children command a vocabulary 
that the totally deaf can never obtain. Their manner of expressing 
their thoughts is equal to that of hearing people. Their readiness to 
speak is surprising. Similar results can never be obtained in totally 
deaf children. They are unattainable to partially hearing children who 
are constantly instructed together with their totally deaf comrades. 
Separation of the partially hearing pupils from the totally deaf ones 
and instruction in separate rooms or if possible in separate institutions 
must be our aim. 

At a meeting of the directors of Bavarian deaf-mute institutions 
in March 1904 the unanimous vote was in favor of separate instruction. 
Since 1900 the board of health of the German empire requires a com- 
plete qualitative and quantitative hearing test by means of the continu- 
ous tone series for all deaf-mute children, of school age. 

This involves the duty upon otologists of carefully testing the 
hearing of each deaf-mute pupil and of deciding which plan of instruc- 
tion he has to follow. This duty is added to that of treating all de- 
structive processes in the ear which may not have subsided when the 
pupil enters the deaf-mute institutions. 

Hard Hearing and Diseases of the Ears in Schools. 

Gentlemen : — The organ of hearing represents the main port of 
entrance for education and mental development. Still a number of 
other influences may help to compensate and even more than compen- 
sate a moderate defect of hearing. A talented child will, in spite of a 
considerably diminished power of hearing, correctly learn to speak at 
the proper age if the parents and older children continually occupy it 
mentally. On the other hand experience has shown that a normally 
hearing child may remain mute if both parents are deaf-mutes and not 
sufficient communication is kept up with other people. 

Nevertheless it must be born in mind that a survey of large masses 
of school children shows that even slight degrees of hard-hearing in- 
terfere with the normal advancement. I found for example in my 
examination of school children x that, placing all children on a basis of 
100, the average rank of the ordinary child is 50th, that of children 
who hear whisper with one or both ears at a distance of 8 meters or less 
is 54th, children who hear whisper with both ears at 4 meters or less 
rank 64th, and those who hear with both ears at 2 meters or less rank 
68th. 

The teacher is not able to recognize pupils with deficient hearing 



1 Schuluntersuchungen uber d. kindl. Gehororgan, Wiesbaden, Bergmann, 1885. 
20 



306 Hard Hearing and Diseases of the Ears in Schools. 

without a systematical hearing test for whisper, especially since the 
majority of cases have remitting and intermitting diseases of the ears, 
occlusion of the tubes, acute recurrences of otitis media, temporary oc- 
clusion of the external meatus with ear wax, purulent secretion, etc. 
These children, on account of the frequent change from good to bad 
hearing, are often misjudged by their teacher and by their relatives. 
They are not considered hard of hearing but inattentive, dull, and in- 
different. 

We even find in the public schools children who are so hard of 
hearing that they learned to speak only very incompletely or not at all. 
Their lot among the good hearing is very dreary. They succumb to 
the scorn of their school fellows and of their teachers who try to shake 
them out of their apparent indifference. Some of them, after use- 
lessly remaining in public schools for several years, finally land in deaf- 
mute institutions where they belonged from the beginning. There such 
children show at first an intimidated expression, their tears appear at 
every occasion. They wake up, gain confidence and become cheerful as 
soon as they enjoy adequate instruction in a class of partially hearing 
deaf-mutes. They are sufficiently intelligent to keep step with the 
others. 

The examination by means of the tone series revealed an extraor- 
dinarily large number of such hard-hearing children in the class rooms for 
backward children which were found in the public schools of Berlin, 
Munich and other cities. To have systematical hearing tests of the 
school-children made ought to be counted among the urgent duties of 
the school boards. The hard hearing children ought to be carefullv 
examined by an otologist who is able to decide whether they are fit for 
taking their instruction in the public schools by sitting close to the 
teacher, or whether they ought to be sent to separate class-rooms for 
hard hearing children or into the hearing class of a deaf-mute institu- 
tion or in the rooms for backward children or finally into an asylum for 
idiots. 

Special credit is due to A. Hartmann in Berlin for the foundation 
of separate schools for hard hearing children. No such separate 
schools can be established in small towns, as each class can only take 
about 10 pupils. Nothing is left under such circumstances but to give 
each pupil separate instruction. 

There are other besides merely pedagogic reasons for instituting 
a careful control of all ears which are only slightly hard of hearing. 

We saw in our statistical explanations about the mortality from dis- 
eases of the ears that nearly 5 per cent of all deaths occurring between 
10 and 30 years are due to suppurations of the middle ear. These dis- 
eases can be traced back to childhood in the majority of cases. They 
begin as simple acute inflammatory diseases and even as simple 
processes in the tubes which are easily amenable to treatment. These 



Hard Hearing and Diseases of the Ears in Schools. 307 



diseases are usually not noticed and not treated among the poorer part 
of the population. Few of these children would then be thus far 
neglected if these diseases were revealed by expert examinations in 
the schools and if adequate instructions were given the parents about 
the dangers of the diseases and the abundant opportunity for treatment in 
free clinics. There is no doubt that the majority of fatal complications 
of diseases of the ears could in future be avoided. 

The other pupils are constantly exposed to the danger involved in 
the dissemination of pyogenous germs emanating from the otorrhoea. 
In my examination of school children I found about one per cent of 
such children. I suggested that they ought to be excluded from school 
at least till the pus does not appear outside of the ear. This request 
was pronounced 20 years ago and has gradually been complied with 
by all intelligent people. 

Children with perforations of f he tympanic membrane ought not 
indulge in shower-baths. 

You see, gentlemen, that in future a large field for beneficial occu- 
pation is awaiting the otologist in deaf-mute institutions. Greater num- 
bers of children may be benefited in public schools when the public and 
especially the school-boards are informed what well-trained eye and 
ear surgeons might accomplish. An adequate number of the latter 
ought to be provided besides the regular school-physicians. 



INDEX. 



Abscess in cholesteatoma, 203 

Caries and necrosis, 225 

Empyema of the mastoid, 179 

In otitis media purulenta acuta, 167 

In otitis media purulenta chron- 
ica, 197 

Of the external meatus, 112 

Extradural, 227 

Subperiostal, 182 
Acoustic nerve tracts in the brain, 285 

Diseases, 281 
Adenoid tissue, 21 
Adenoids hyperplasis, 13-4 
Adhesive processes in the middle 

ear, 248 
Aditus ad antrum anatomy, 8 

Examination, 203 

Diseases, 206 

Position, 43 
Air conduction, 56, 69 
Amplitudes of vibration in tuning 

forks, 60 
Ampullae, 55 

Ancylosis of the stirrup, 250 
Aneurysms in the surroundings of 

the ear, 261 
Angioma, 90 
Annulus tympanicus, 38 
Antogomism of the muscles in the 
middle ear, 49 

Of radial and circular fibres of the 
tympanic membrane, 48 
Antipyrin, 272, 284 

Antiseptic treatment of acute purulent 
otitis media, 175 

Of chronic suppuration of the mid- 
dle ear, 197 
Antrum mastoideum anatomy, 110, 205 

Opening by operation, 185 

Position, 10-33 
Antrum tube, 206 
Aphasia, 269 
Aprosexia, 136 
Aquaeductus cochlea?, 14 

Vestibuli, 14 



Argentum intricum, 205 

Arsenic acid as cause of disease of the 

inner ear, 283 
Arthritis of the auricle, 90 
Aspergillus, 116 
Atresia of the meatus, congenital, 99 

Acquired, 103 
Auditory nerve diseases, 281 
Auscultation tube, 25 
Autophonia, 23, 154 

B 

Bacillus pyocyaneus, 88, 112, 121 
Bacteriologic findings in otitis media 
purulenta acuta, 156 

Chronica, 194 
Bezold's mastoiditis, 183, 187 
Bing's test, 70 
Blisters, hemorrhagic, 161 

Serous, 161, 165 
Bone conduction, 65, 68, 69, 101, 147 

244, 266, 268 
Boric acid, 174, 175 

In acute suppuration of the middle 
ear, 174 

Chronic, 198-205 

Eczema, 85 
Bougies in the tube, 20 
Bulb of the jugular vein, 16 

In operation, 187 

Anatomic variations, 18 
Button shaped granulations, 172, 177, 
225 



Canal of the facial nerve, 8 

Position, 11 
Canalis Fallopii, same as Canal of the 

Facial Nerve. 
Carcinoma of the external ear, 95 

Middle ear, 260 

Inner ear, 281 
Caries of the ossicles, 173 

In the middle ear, 181, 203, 210, 215 
Catarrh of the middle ear, 131 
Cartilago quadrangularis, 24 
Catheter in children, 19, 21, 26, 151 



308 



Index 



309 



Cells, pneumatic, 9-11 

Pathologic changes, 180, 186 
Central tracts of the auditory nerve, 281 

Diseases, 285 
Cerebro-spinal meningitis, 274 

Cause of deaf -mutism, 299 
Chenopodium intoxication with the 

oil, 283 
Chill, 233 
Chissel, 186, 187 
Cholesterin crystals, 193 
Cholesteatoma of the external mea- 
tus, 109 

Of the middle ear, 201 , 205, 246 

Formation of cavities, 260 

A cause of panotitis, 208 
Chorda tympani, 42 

Paralysis, 204 
Cisterna perilymphatica, 13 
Cleft palate, 29 
Cochlea, 6, 54, 170 
Collapse of the tympanic membrane 

149, 150 
Commotion of the labyrinth, 128, 294 
Complications endocranial, 220, 227 
Concha, and Auricle, 32 

Function, 47 
Condylomata lata in the meatus, 114 
Consonants, pitch of, 71, 302 
Conversation, 71 
Corti's organ, 13 

Function, 54 

Pathology, 265 
Corrosion specimen, 8 
Cretinism, 273 
Crista temporalis, cells, 11 

In infants, 34 
Croupous inflammation of the external 
canal, 119 



Deafness, 266 

In diseases of both windows, 52 

Examination, 64 

In suppuration of the middle ear, 64 

In injury to the labyrinth, 292 
Deaf-mutism, 296 

Education, 303 

Statistics, 297 
Deformities of the Auricle, 81 
Dermatitis phlegmonosa of the au- 
ricle, 88 
Detonation, 294 
Diabetes, 187, 220, 227 
Diagram of hearing, 60 



In necrosis of the labyrinth, 226 
Diphtheria bacillus, 156 
Diphtheritic changes as cause of deaf- 
mutism, 300 

In the inner ear, 278 

In the middle ear, 168 
Diplococcus pneumoniae 156, 168, 184 
Disturbance of equilibrium in beginning 
suppuration of the labyrinth, 223 

In diseases of the inner ear, 269 

Otosclerosis, 255 
Dizziness, 55 

In cholesteatoma, 204 

In diseases of the inner ear, 269 

In fracture of the base of the skull, 
128, 293 

In otitis media purulenta acuta, 185 

In otosclerosis, 254 
Ductus cochlearis, or spiralis, 13 

Deformities, 265 
Ductus subarcuatus, 12 
Dvsacusis, 249 



Eczema of the auricle and meatus, 81 

Secondary, 85 
Education of deaf-mutes by aural 
method, 296, 302 
Articulation, 296 
Emmisarium mastoideum, 11, 12, 185 
Emphysema, 25 
Origin, 27, 90 
Empyema of the saccus endolympha- 
ticus, 222 
Of the mastoid cells, 179 
Endolymph, 14, 15 
Endostium of the labyrinth, 265 
Epidermisation of the middle ear, 191, 

201 
Epithelium of the middle ear, 131 
Epithelial carcinoma of the auricle and 

meatus, 96 
Epithelioma cicatricans, 96 
Erosion of the bone in empyema of the 
mastoid, 180 
In cholesteatoma, 262 
Erysipelas of the auricle, 88 

As cause of suppuration of the mid- 
dle ear, 168 
Secondary, 89 
Examination of school children, 41, 

72, 305 
Exostosis of the meatus, 102 
Extradural abscess, 112 
Extravasation of blood, 161 



310 



Index. 



Exudation into the spaces of the middle 
ear, 156 
Absorption, 168 



Facial paralysis in acute suppuration of 
the middle ear, 173 

In cholesteatoma, 204 

In diseases of the midbrain, 286 

In epithelial carcinoma, 197 
Facial paralysis in herpes, 90 

In necrosis of the labyrinth, 225 

In noma, 93 

In otitis media phthisica, 21b 

In scarlet fever, 173 

In trauma, 290 
False membranes, 125, 212 
Fetor, 193 
Fibrinous exudation on furuncles, 112 

On the tympanic membrane, 119 
Fibrosarcoma of the naso-pharynx, 141 
Finger protector, 135 
Fissura Glaseri, 43 

Mastoideo-squamosa, 34 

Perforation, 183 
Fistula auris congenita 81 
Fistula in cholesteatoma, 204 

In empyema of the mastoid bone, 
182, 200 

In the meatus, 41, 182 

In the promontory, 195 
Folde, posterior, in the tympanic mem- 
brane, 145 
Foreign bodies in the meatus, 104 
Formalin, 199 
Fossa digastrica, see incisura mastoidea 

Intercruralis, 86 

Mastoidea, 99 

Perforations, 105 

Navicularis, 81 
Fracture of the basis of the skull, 127, 
290 

Meatus, 108 

Of the temporal bone, 77, 292 
Function of the organ of hearing, 6 
Functional tests of hearing, general 
part, 5, 56, 78 

In atresia of the meatus, 101 

In diseases of the inner ear, 265 

In otitis media acuta, 161 

Otosclerosis, 252 

Occlusion of the tubes, 145 
Furuncles of the external canal, 111 

In suppuration of the middle ear, 175 



Galton's whistle, 57 

In otitis media purulenta acuta, 173 
Galvanisation, 272 
Galvanocautery, 105, 177, 187 
Galvanolysis of the tube, 18 
Gaps in the range of hearing, 53, 58, 63 
Gelle's test, 70 

Germs of infection, 131, 133, 156 
Glandula parotis, 35, 39 
Gottstein's knife, 140 

Tampon in the nose, 153 
Granulations in acute suppurations, 172 

In chronic suppurations, 195 

In the middle ear, 180 



Hammer, 6 

Axis ligament, 49 

Handle, 42 

Short process, 42 

Rudimentary, 101 
Harmonica of Urbantschitsch, 301 
Hearing distance for speech, 73 

For numerals, 75 
Hearing tests, 58 

Speech, 70 

Tones, 56 
Helmholtz's theory, 54 
Heredity of otosclerosis, 252 
Herpes, 90 

In otalgia, 258 
Hutchinson's triad, 276 
Hyperesthesia for sounds, 126 
Hyperostosis of the meatus, 102 
Hyperplasia of the tonsils, 141 
Hysteria, 289 

In suppuration of the middle ear, 242 



Ice-bag, 165, 175 

Illumination of the tympanic mem- 
brane, 40 
Incisura mastoidea, 9 

Perforation, 239 
Incisura Rivini, 41 
Incisura Santorini, 35 
Infarction, 232 
Infectious diseases, 130, 189 
Inflation of air through the meatus, 152 

Through the nose, see Politzer's 
method 
Influenza, 161, 163 

Bacillus, 156 



Index. 



311 



Diseases of the inner ear, 279 

Otitis, 170, 173, 177 
Insufflation of boric acid, 152 

In acute suppuration, 175 

In chronic suppuration, 199 

Into the aditus ad antrum, 207 
Internal carotid artery dehiscencies in 
the walls, 15 

Hemorrhages, 143 

Injuries, 193 
Intrinsic muscles of the middle ear, 56 
Islands of hearing, 53, 58, 63 
Iodine, 164 
Iodide of potassium in otosclerosis, 257 

In syphilis, 277 
Iodoform dressing, 187 

Eczema, 84 



Kassowitz emulsion 285 
Kundt's tubes, 57 



Labyrinth, membranous, 13 

Bony, 13 

Deformities, 265, 299 

Fractures, 128, 291, 292 

Hemorrhages, 292 

Necrosis, 220 

Perforation of pus, 15 
Labyrinthitis, 220, 265, 274 
Lamina cribrosa, 14 
Lassar's paste, 83 
Lead poisoning, 283 
Leeches, 176 
Leptomeningitis, 240 
Leucemia, 274, 279, 282 
Limbus tendinosus of the tympanic 

membrane, 41, 43 
Liquor cerebrospinalis, 125, 128, 293 
Lucae-Dennert's test, 225 
Lucae's double bulb, 30, 150 
Lues hereditary, 276 
Lumbar puncture, 241 
Luxation of the hammer and anvil, 128 

Of the stirrup, 107 
Lymphangitis, 83, 135, 183, 185, 213 

M 

Malaria, diseases of the inner ear, 283 

Margaritoma, 261 

Margo tympanicus, 192, 195 

Massage of the tube, 19 

Mastoiditis, 179 



Measles changes in the middle ear, 168, 
179 

As cause of otitis media purulenta 
chronica, 189 

And diseases of the inner ear, 278 

In deaf-mutism, 300 
Meatus cartilaginous, 35 

Casts, 35 

Diseases, 99 

Epidermis, 109 

Fistula, 41 

Fracture, 109 

Function, 6, 46 

Granulations, 110 

Isthmus, 36 

Topography, 110 
Membrana basilaris, 54 

Flaccida, 42 
Membrana tympani, perforations, 190, 
201 

In scarlet fever, 191 

Retraction, 145 
Meniere's complex of symptoms, 270 

After operation, 187, 240 
Meningitis and perforation into the 
labyrinth, 222 

In otitis media purulenta acuta, 185 

Phthisica, 213 

Serosa, 241 

Tuberculosa, 214, 242 
Meningococcus, 156 
Metastases, 232-233 
Midbrain deafness, 285 

Tumors, 286 
Middle ear lining, 130 

Diseases, 130 

Topography, 8 
Mortality from diseases of the ears, 2 
Mouth breathing, 137 
Mucor, 116 
Muscles of the tubes, 22, 23, 137 

Stapedius, 13, 32, 49 

Tensor tympani, 49, 50, 127 
Mumps, diseases of the inner ear, 279 

And deaf -mutism, 300 
Myringitis acuta, 123 

Chronica, 123, 193 



Naphthalan, 84 

Nasal douche, Weber's, 153 

Nasal cavity, 24, 141 

Septum, 24 
Naso -pharynx, 20 

Probe, 153 



312 



Index. 



Necrosis of bone, 114, 198, 210, 216 
Nervus abducens, 238, 287, 293 

Glosso-pharyngeus, 293 

Hypoglossus, 286, 287 

Oculomotorius, 287, 293 

Trochlearis, 293 

Vagus, 293 
Neurasthenia, 290 

Neuritis of the auditory nerve, 265, 281 
Neuro-glioma of Gasser's ganglion, 142 
Neuroma in the vestibulum, 279 
Neurosis motor, 259, 293 
Nicotin, intoxication, 283 
Noise, 56, 259 

Subjective in cholesteatoma, 205 

In irritation of the labyrinth, 221 

In otosclerosis, 255 

In residues, 243 

In occlusion of the tubes, 147 

Of perforation, 126, 171 
Noma 90 
Numerals as test words, 72-74 

O 

Occlusion of the meatus, 109 

Of the tubes, 21, 133, 134 

Of the tubes as cause of otitis media 
purulenta chronica, 190, 211 
Oleum cadini, 84 

Fagi, 84 

Hyoscyami, 259 

Rusci, 84 
Orthoform, 84, 85 
Ossicles, 6 

Lever apparatus, 47 
Osteoblasts, 181 
Osteoclasts, 180 
Osteoid substance in the middle ear, 181 

Labyrinth, 265 
Osteophlebitis, 231 
Ostitis, rarefying, 181 
Ostium pharyngeum of the tube, 20, 25 

Tympanicum, 8, 193 
Os tympanicum, 35 

Absence of, 101 

In the new born baby, 38 

Exostoses, 102 

Necrosis, 114 
Otalgia, 258 
Othematoma, 86 
Otitis externa circumscripta, 111 

Crouposa, 119 

Diffusa, 113 

Otitis media purulenta, 133, 167 



Media purulenta chronica, 133 
Otitis media purulenta with central 
perforation, 197 

Marginal perforation, 201 
Otitis media phthisica, 210 

Simplex acuta, 133, 160 

Simplex chronica, 133, 247 
Otoliths, 55 
Otomycosis, 115, 119 
Otosclerosis, 133, 250, 284 
Ozena, 153 



Palpation of the naso-pharynx, 135, 138 
Panotitis, 220 

In cerebrospinal meningitis, 274 

In otitis media purulenta acuta, 185 

In otitis media purulenta phthisica, 
213 

Traumatic, 221 
Paracentesis of the tympanic mem- 
brane, 97, 151, 165, 174 
Paracusis Willisii, 255 
Parotitis, 90 
Pars flaccida Shrapnelli, 42 

Tensa, 42 
Pearl tumor, 261 
Pelvis ovalis, 49 
Pemphigus, 114 
Penicillium, 116 
Perception, 57, 60 
Perichondritis, 87 
Percussion of the mastoid bone, 262 
Perilymph, 13 
Pharyngitis sicca, 139 
Phosphorus in otosclerosis, 257, 285 
Pitch of vowels and consonates, 302 
Pneumomassage, 257, 272 
Pneumonia, disease of the inner ear, 

279, 300 
Politzer's method, 19, 30, 164 

In otitis media chronica, 199 

In otitis media acuta, 174 

In otitis media simplex acuta, 166 
Polyneuritis of the auditory nerve, 281 
Polyps, 194, 198 

In the meatus, 114, 121 

Removal, 177, 199, 207 
Porus acusticus internus, 10 
Presbyacusis, 272 
Preysing's knife, 239 
Prolapse of the brain, 240, 260 
Promontory, 13 
Pruritus meatus, 124 



Index. 



313 



Quadrants of the tympanic mem- 
brane, 42 
Quinine, 272, 284 
Poisoning, 283 



Radical operation, 34, 98, 208, 217, 

219, 223, 225, 292 
Raref actor Delstanche, 247 
Reflex on the tympanic membrane, 44 

Pathologic, 145, 149 
Reflex movements of the eyes, 55 
Reflex neurosis of the meatus, 105 
Regeneration of the facial nerve, 226 
Remnants of hearing, 301 
Reserve air for speaking, 71 
Residues, 150, 243 
Resorcin, 200 

Retinitis pigmentosa, 273, 299 
Retropharyngeal abscess, 184 
Rhinitis atrophicans, 142 
Rhinoscopia, 135 
Rhinoscleroma, 141 
Rinne's test, 68 

In diseases of the inner ear, 268 

In otitis media acuta, 162 

In otosclerosis, 254 
Rosenmuller's fossa, 20 
Rupture of the tympanic membrane, 
78, 109, 124 



Sacculus, 14, 55 

Salicylic acid causing deafness, 283 

Alcoholic solution, 110, 119 
Salpingoscope of Lindt, 262 
Sarcoma, 95, 260, 280 
Scala tympani, 13 

Scarlet fever, 168, 173, 179, 278, 299 
Schwabach's test, 67, 268, 253 
Schwartze's operation, 186, 218 
Scrofulosis, 212, 215 
Secretion in acute suppuration, 170 

In chronic suppuration, 193 

Of the lining of the middle ear, 131 
Semicircular canals, pathology, 204 
Sensitiveness of the mastoid region, 

17, 185 
Sepsis, 198, 236 
Septicopyemia, 233 
Sequestrum, external ear, 115 

Middle ear, 183 

Inner ear, 220 



Shrapnell's membrane, see flaccida 
Siegle's otoscope, 149, 247 
Sinus phlebitis, 231, 234, 239, 293 
Snare, 140, 200 

Wilde's, 177 
Soft palate, 21, 23 
Sound conducting apparatus, 47, 48, 62 

Fixation, 70, 250 
Sound waves, 66 
Speech, 70, 74 

Spina supra meatum, 16, 17, 32, 186 
Stapes, 13, 49 

Ancylosis, 250 

Movements, 15, 47 

Luxation, 107, 241 
Streptococcus pyogenes, 156, 168, 194 
Stylo-mastoid foramen, 15 
Suppuration of the middle ear, 11 

Invasion of the labyrinth, 107 

As cause of deafness, 300 
Sutura, mastoideo -squamosa, 183 
Syphilis, 216, 220 

Of the labyrinth, 276 

And neuritis of the auditory nerve, 
282, 284 

A cause of deaf -mutism, 300 



Tabes, a cause of disease of the acoustic 

nerve, 282 
Tegmen tympani et antri, 8, 11 

Injuries, 125, 128 
Terminal cells, 9 
Temperature in acute sepsis, 236 

In acute suppuration, 170 

In sinus thrombosis, 234 
Tenotomy of the tensor tympani mus- 
cle, 107 
Thiersch's grafts, 95, 97 
Thiosinamin, 285 

Thrombophlebitis, 194, 231, 232, 233 
Tinnitus aurium, 271 
Tobacco intoxication, 283 
Tone-limit, 57, 64, 185, 266, 268 
Tone-series, 5, 55, 56, 59, 301 
Toynbee's test, 143 
Tragus, 35 
Trauma, acoustic, 294 

Electric, 295 

Inner ear, 290 

Tympanic membrane, 124 

Deaf -mutism, 3C0 
Tuba Eustachii, 8, 21, 22, 154 
Tuberculosis, 280 



314 



Index. 



In neuritis of the auditory nerve, 281 
Tumors of the brain, 242, 286, 287 
Tympanic membrane, 5, 18, 39, 48, 77 

Adhesions, 248 

Atrophy, 149, 247 

Chalk deposit, 247 

Erysipelas, 88 

Folds, 145, 248 

Ruptures, 78, 109 

Scars, 125, 243, 247 
Typhoid fever, inner ear, 279 

Middle ear, 165 

Polyneuritis, 282 

Deaf -mutism, 300 

U 

Umbo of the tympanic membrane, 18 
Utriculus, 14 
Function, 55 

V 

Valsava's test, 31, 175 
Variability of the ear, 13 



Ventricles, perforation of abscesses of 

the brain, 237 
Vowels, 70-302 



W 



Weber's test, 64, 162 
Whisper, 47, 71 
Wilde's snare, 177, 200 
Wilde's incision, 186 
Windows, oval, 63 

Physiology, 119 

Round, 13 



Yearsley's ball of cotton, 216, 246 



Zincoxyde paste, 79 

Zittmann's decoction, 277 

Zona pectinata of the chochlea, 54 



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